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Text-Book of Hygiene 



A COMPREHENSIVE TREATISE 



Principles and Practice of Preventive Medicine 



FROM AN AMERICAN STAND-POINT, 



QBOROE H. ROHB M.D., 

PROFESSOR OF OBSTETRICS AND HYGIENE IN THE COLLEGE OF PHXSICIANS AND SURGEONS, BALTIMORE ; DIRECTOR OF 

THE MARYLAND MATERNIT:^ ; MEMBER OF THE AMERICAN PUBLIC HEALTH ASSOCIATION ; FOREIGN 

ASSOCIATE OF THE SOCIETE FRAN9AISE D'HYGIJINE, OF THE SOCIETE DES CHETALIERS- 

SAUTETEURS DES ALPES MARITIMES, ETC. 



3 



>7 



Thoroughly Revised and Largely Rewritten, with Many 
Illustrations and Yaluable Tables. 




<^^ COPYRIGHT ^\ 

P.FP151890 ' 



PHILADELPHIA AND LONDON: 

F. A. DAVIS, PUBLISHER, 

1890. 



.^ 



Entered according to Act of Congress, in the year 1890, by 

F. A. DAVIS, 

In the Of&ee of the Librarian of Congress, at Washington, D. C, U. S. A. 



Pliiladelphia, Pa., U. S. A. : 

The Medical Bulletin Printing House, 

1231 Filbert Street. 



TO 



HENRY INGERSOLL BOWDITCH, A.M., M.D., 



IN THE FIELD OF 



»E2.E"VE3SrTI-VE KEEZSICiaSTE 



AI^EItlCA. 



(iii) 



PREFACE TO THE FIRST EDITION. 



The aim of the author in writing this book has been to 
place in the hands of the American student, practitioner, 
and sanitary officer, a trustworthy guide to the principles 
and practice of preventive medicine. 

He has endeavored to gather within its covers the essen- 
tial facts upon which the art of preserving health is based, 
and to present these to the reader in clear and easily 
understood language. 

The author cannot flatter himself that much in the 
volume is new. He hopes nothing in it is untrue. 



(V) 



PREFACE TO THE SECOND EDITION. 



In the present edition the author has endeavored to in- 
corporate the advances made in sanitary science and art since 
the issue of the first edition. 

Additions will be found upon nearly every page, and 
some of the chapters have been almost entirely rewritten. 
The size of the book has been increased about one hundred 
pages, and illustrations have been introduced wherever 
thought requisite. The thanks of the author are due to 
Medical Director Albert L. Gihon, United States Navy, for 
revising the chapter on Naval Hygiene, and to Surgeon 
Walter Wyman, United States Marine-Hospital Service, for 
supplying the chapter on Quarantine. 



(vii) 



TABLE OF CONTENTS. 



CHAPTEE I. 
Air, 1 

CHAPTEE 11, 
Water, 45 

CHAPTER HI. 
Food, 81 

CHAPTER IV. 
Soil, . 121 

CHAPTER V. 
Removal of Sewage, 135 

CHAPTER VI. 

Construction of Habitations, . . . . .151 

CHAPTER VII. 

Construction of Hospitals, . . . . . .179 

CHAPTER VIII. 
School of Hygiene, 192 

CHAPTER IX. 

Industrial Hygiene . . . . . . .207 

CHAPTER X. 

Military and Camp Hygiene, . . . . . .231 

(ix) 



X TABLE OF CONTENTS. 

CHAPTER XI. 
Naval Hygiene, 243 

CHAPTER Xn. 
Prison Hygiene, 255 

CHAPTER XIH. 
Exercise and Training, 261 

CHAPTER XIV. 
Baths and Bathing, . 267 

CHAPTER XV. 
Clothing, . . . 275 

CHAPTER XVI. 
Disposal of the Dead, .279 

CHAPTER XVII. 

The Germ Theory of Disease, 285 

CHAPTER XVIII. 
Contagion and Infection, 289 

CHAPTER XIX. 

History of Epidemic Diseases, 293 

CHAPTER XX. 

Antiseptics, Disinfectants, and Deodorants, . . 347 

CHAPTER XXL 

Vital Statistics, 359 

CHAPTER XXII. 
Quarantine, 365 

Index, 417 



Text-Book of Hygiene, 



CHAPTER I. 

Air. 



Exact investigation into the influence of the atmosphere 
upon health is yet in its infancy. Enough has been learned, 
however, to show that changes in the composition of the air, in 
its density, its temperature, its humidity, its rate and direction 
of motion, and possibly its electrical or magnetic conditions, 
influence in various ^vays the health of the individual. It is 
only very recently that any scientific attempts have been made 
to trace the bearing of atmospheric changes upon health. The 
observations already recorded indicate that a thorough study of 
meteorological phenomena in connection with the origin and 
progress of certain diseases is a promising field of labor for the 
educated sanitarian. The meteorological observations which 
have been gathered by the United States Signal Service during 
the past eighteen years, together with the elaborate studies 
made by the meteorologists and climatologists of other countries, 
already form such a large and tolerably complete and well- 
arranged body of facts, that reasonably accurate deductions can 
even now be made. Heretofore, in studying the sanitary rela- 
tions of the atmosphere, both in this country and abroad, the 
attention of observers has been riveted almost exclusively upon 
the changes in its composition occurring within certain limited 
areas. It is, perhaps, equally important to study this universally 
diffused and necessary condition of vital activity in its broader 
and more general relations. It will be shown, in the course of 
the present work, that the meteorological features of countries, 

(1) 



2 TEXT-BOOK OF HYGIENE. 

or of seasons, or even the daily atmospheric changes, exercise an 
important influence upon life and health. In order to fully 
appreciate these relations it will be necessary to first give a brief 
summary of the facts and laws of meteorology. 

THE COMPOSITION' AND PHYSICAL CONDITIONS OF THE ATMOSPHERE. 

Atmospheric air is a mixture of four-fifths of nitrogen and 
one-fifth of oxygen; more accurately, 79.00 of the former to 
20.96 of the latter. In addition, there is constantly present a 
modicum of carbon dioxide, usually a little over .03 per cent. 
(3 to 4 parts in 10,000), traces of ammonia and nitric acid, and 
a variable proportion of vapor of water. 

These proportions are maintained, with but very little 
change, at different heights. At first thought, it would seem 
that carbon dioxide, being much heavier than the other con- 
stituents of air, would accumulate in the lower regions of the 
atmosphere, and there cause an excess of this poisonous con- I 
stituent, but in obedience to the law of diffusion the interming- 
ling of the component gases is perfect, and the proportion of 
carbon dioxide in the atmosphere is quite as great on mountain- 
tops as in the deepest valleys. 

The proportion of nitrogen in atmospheric air is generally 
uniform, while that of oxygen varies, depending to a great ex- 
tent upon the amount of carbon dioxide present. Hence, an 
increase in the amount of the latter constituent is usually ac- 
companied by a diminution of oxygen, inasmuch as the formation 
of carbon dioxide can only take place at the expense of oxygen. 
The reciprocal activities of animal and vegetable life are beauti- 
fully illustrated by these relations between the oxygen and 
carbon dioxide in the air. In the processes of combustion and 
oxidation, oxygen is withdrawn from the atmosphere, and com- 
bines with carbon, forming carbon dioxide. During vegetable 
growth, on the other hand, carbon dioxide is withdrawn from 
the air by the leaves of plants, and decomposed into its elements, 
carbon and oxygen. The carbon is used in building up the 



COMPOSITION AND PHYSICAL CONDITIONS OF ATMOSPHERE. 6 

plant, while the liberated oxygen is restored to the atmosphere. 
The animal consumes oxygen, and gives out carbon dioxide; 
the plant resolves this compound into its constituent elements, 
and gives back the oxygen to the air again. 

Some recent experiments of Jolly have show^n that on days 
of northerly winds the proportion of oxygen is higher than the 
average, while under the influence of the south wind the propor- 
tion of oxygen is deficient. The extremes in a series of 21 
observations were 21.01 and 20.53 per cent. The diflerence, 
AS per cent., is too small to have any appreciable influence 
upon health. 

The atmosphere extends upward from the surface of the 
earth to an indefinite distance. The limit has been variously 
placed at from 75 kilometres to 40,000 kilometres. For all 
sanitary purposes the former may be taken as the upward limit 
of the atmosphere. In obedience to the law of gravity, this 
mass of air everywhere presses directly downward — toward the 
earth's centre — with a force equal to its weight. If a column 
of this air be balanced by a column or mass of any other matter — 
the columns being of the same diameter — we have a relative 
measure of the weight of the atmosphere. The instrument with 
which the weight or downward pressure of the air is measured 
is called a barometer. The atmosphere, at the sea-level, presses 
downward with a force equal to the pressure of a column of 
mercury 760 millimetres high. Hence, the barometric pressure 
at sea-level is said to be 760 millimetres, or 30 inches. If the 
barometer be carried to the summit of a mountain 1000 metres 
above the level of the sea, or taken to the same altitude in a 
balloon, the mercury in the barometer-tube will fall about 
90 millimetres. These 90 millimetres of the mercurial column 
represent the weight of 1000 metres of air now below the 
barometer, and consequently not measured or balanced by it.^ 

Upon ascending from the sea-level, it is found also that the 

* The figures here given are not absolute, but merely approximate. The limits of this 
work do not allow a full discussion of the meteorological elements modifying the pressure of 
the atmosphere at sea-leveL 



TEXT-BOOK OF HYGIENE. 



air, being less pressed upon by that which is still above it, 
becomes more rarefied and lighter; its tension, as it is termed, 
is less. Hence, for the second 1000 metres of ascent above the 
sea, the mercury will fall a less distance in the tube, the weight 
removed not being so great as in the first 1000 metres. 

The following table shows the diminution in atmospheric 
pressure for every 1000 metres above sea-level: — 

Table I. 

Height. Barometric Pressure. 

, T60.0 millimetres. 

. 670.4 " 

. 591.5 " 

. 521.0 " 

. 460.3 " 

. 406.0 " 

. 358.2 " 

. 816.0 " 

. 278.8 " 

. 245.9 " 

. 216.9 " 

. 191.1 " 

. 168.8 " 

. 115.9 " 

. 61.9 " 

Variations in temperature and humidity of the air influence 
the tension of the atmosphere in a marked degree, and affect 
the height of the barometric column. In fact, most of the 
changes of atmospheric pressure at the surface of the earth are 
directly due to changes in temperature and humidity. Increase 
of temperature diminishes the density of the air. Hence, when 
the temperature rises the pressure decreases. 

The proportion of moisture (aqueous vapor), if increased, 
likewise causes a diminution in pressure. It is found, for ex- 
ample, that when the amount of aqueous vapor in the air 
increases the barometer falls. This is due to the fact that the 
specific gravity of aqueous vapor is less than that of dry air, 
being in the proportion of .623 to 1.000. Hence, as aqueous 



ioea,-ievei, 






1,000 metres, 




2,000 " . 




3,000 " 






4,000 " 






5,000 " 






6,000 " 






7,000 " 






8,000 " 






9,000 '' 






10,000 " 






11,000 " 






12,000 " 






15,000 " 






20,000 '' 







COMPOSITION AND PHYSICAL CONDITIONS OF ATMOSPHERE. 5 

vapor is diffused through air, the latter becomes Hghter, — or, in 
other words, the barometric pressure diminishes. 

The warmth of the air is primarily derived from the sun. 
On a clear day about one-fourth of the heat of the sun's rays is 
given off directly to the air during the passage of the heat- 
rays to the earth. Of the remaining three-fourths, part is re- 
tiected from the earth, while the larger portion is first absorbed 
by the earth, and then given off by radiation and convection to 
the superincumbent air. 

The air is always warmer near the earth's surface on a clear, 
sun-shiny day; for, as soon as the earth gets warmer than the 
air immediately above it, the excess of heat is given off to the 
latter by convection and radiation. On ascending from the 
surface of the earth the temperature decreases, and on the 
summit of a high mountain the air is always colder than at 
its base. 

Professor Tyndall has shown that dry air absorbs less 
heat than air which is charged with vapor. For this reason 
the sun's rays strike the earth with much greater intensity 
on a very dry than on a moist day, while on the latter a larger 
proportion of the heat-rays is intercepted before they reach 
the earth. 

Recent experiments seem to show, however, that the differ- 
ence in diathermancy between dry and humid air is not so great 
as supposed by Tyndall. The depth of the air-stratum, through 
which the sun's rays pass, is of greater influence than the 
humidity. 

Air, at different temperatures, is capable of absorbing 
different amounts of aqueous vapor. Thus, air at a temperature 
of 4° will require a much smaller amount of vapor to produce 
saturation than air at a temperature of 30°. For this reason 
air which appears " damp " at the former temperature, both to 
the bodily sensations and to appropriate instruments, would be 
considered as "dry" at the latter temperature, although the 
actual amount of vapor present, or absolute humidity, is the 



b TEXT-BOOK OF HYGIENE. 

same in both cases.^ In meteorological observations for sanitary 
purposes, the relative humidity is the condition deserving 
especially careful study. 

It must be borne in mind that the m.ere statement of the 
percentage of relative humidity, w^ithout taking into account the 
temperature of the air, is of little significance. A like remark 
is justified with regard to statements of absolute humidity, when 
used to illustrate the apparent effects of atmospheric moisture 
upon life and health. 

The following table shows the absolute humidity coiTe- 
sponding to the same relative humidity at different tempera- 
tures. It also includes the total possible absolute humidity 
and the difference between the actual and possible humidity 
(deficiency of saturation) at the temperatures given : — 



Table II. 



Tempera- 
ture °U. 


Relative 
Humidity 
(per ceut.). 


Absolute Humidity 
(grammes per 
cubic metre). 


Greatest Possible 
Absolute Humidity. 


Deficiency of 
Saturation. 


—20 

—10 



+10 
20 
30 


60 
60 
60 
60 
60 
60 


0.638 
1.380 
2.924 
5.623 

10.298 

18.083 


1.064 
2.300 
4.874 
9.372 
17.164 
30.139 


0.426 
0.920 
1.950 
3.749 
6.866 
12.056 



In forests the relative humidity is usually higher than over 
unwooded districts, although the absolute humidity may be the 
same, or, perhaps, even less. The evaporation is usually much 
greater in the open air than in forests. In closed apartments 
the evaporation may be greater or less than in the open air, de- 
pending upon the local conditions present. 

» By '•absolute humidity" is meant the total amount of vapor present in a certain mass 
of air. By the term "relative humidity " meteorologists designate the proportion of vapor 
present at certain temperatures, compared with full saturation of the air with vapor, which is 
reckoned 100. Thus, air which is saturated, or whose relative humidity is 100 at 4°, would have 
a relative humidity of only 24, if the temperature were raised to 27°, because in the latter case 
the capacity of the air for aqueous vapor is increased. Relative humidity is always designated 
in percentages ; absolute humidity in grammes per cubic metre or grains per cubic foot. 



COMPOSITION AND PHYSICAL CONDITIONS OF ATMOSPHERE. 7 

The motion of the air— wind— is caused by difFerenecs in 
pressure ; the latter being due to differences in temperature and 
humidity. A mass of air traversing a large body of water absorbs 
vapor, unless ah'eady saturated, and becomes moist ; if it pass 
over a wide tract of dry land it loses moisture and becomes dry. 
Therefore in the eastern portion of the American continent, an 
easterly or southerly wind, which comes from over large bodies 
of water, and which is usually warm, and thus capable of hold- 
ing a large quantity of water in a state of vapor, is always 
moist. On the other hand, a northerly or westerly wind, com- 
ing over a large extent of dry land, and from a colder region, is 
nearly always a dry wind. On the Pacific coast these condi- 
tions are reversed; there a westerly wind is a moist wind, while 
an easterly wind is dry. The dreaded easterly wind of England 
is likewise a dry wind. It is probable that the direction and 
rate of motion of air-currents have considerable influence upon 
the origin or intensification of certain diseases. 

The electrical and magnetic conditions of the atmosphere 
have been as yet studied to little advantage. It is only known 
that atmospheric electricity is, in most cases, positive, and that 
its intensity increases with condensation of vapor. There seems 
to be no doubt that the varying states of atmospheric electricity 
are closely connected with evaporation and condensation. There 
is reason to believe that a fuller knowledge on these topics will 
yield most important resuUs to the student of hygiene. 

Ozone and antozone, or hydrogen peroxide, are usually 
present in the atmosphere in varying proportions. Careful and 
extended observations have failed to show any connection be- 
tween the presence of these agents in the atmosphere and modi- 
fications of health. It is probable that the sanitary importance 
of ozone and of hydrogen peroxide have been much overrated. 
It is not known that either of these substances has any other 
function in the atmosphere than that of an oxidizing agent. 

The sanitarian should be a practical meteorologist. In 
addition to a knowledge of the principles of the science, he 



8 



TEXT-BOOK OF HYGIENE. 



should possess the skill to make accurate observations of me- 
teorological conditions, and estimate their significance. But the 
acquisition of an elaborate collection of instruments, and their 
regular observation, is too expensive and time-consuming. A 

German physicist, Lambrecht, has de- 
vised an instrument which combines in 
itself nearly all the requirements of a 
trustworthy meteorological instrument 
(Fig. 1). This instrument is called a 
polymeter, and shows, on easily-readable 
scales, the temperature, relative humid- 
ity, dew-point, absolute humidity in 
grammes per cubic metre, and vapor 
tension. 

INFLUENCE OF CHANGES OF ATMOSPHERIC 
PRESSURE ON HEALTH. 

The effects of a considerable dimi- 
nution of pressure are familiar to every 
one in the '• mountain sickness " which 
attacks most persons on ascending high 
mountains. M. Bert has shown experi- 
mentally that similar effects can be 
produced in an air-tight chamber by 
diminishing the pressure.^ The symp- 
toms produced under a pressure equiva- 
lent to an altitude of from 4000 metres 
to 5000 metres were a feeling of heavi- 
ness, nausea, ocular fatigue, rapidity 
of pulse, convulsive trembling on slight 
exertion, and a sensation of languor 

and general indifference to the surroundings of the individual. 
M. Lortet, who has left on record his experiences in the 

higher Alps, says that the symptoms noticed on ascending to 

> Popular Science Monthly, v, p. 379. 




Fig. 1. 

liAMBRBCHT'S POLYMETEB. 



INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE. 9 

high altitudes are : Labored respiration, increased rapidity of 
pulse, depression of temperature (as much as 4° to 7° C). The 
normal temperature was restored, however, after a brief rest.^ 
Still more severe symptoms have been noticed on ascending high 
mountains m South America and Asia. Aeronauts have lost 
consciousness, and in several instances life, on rapidly ascending 
to great altitudes.^ According to the observations of the 
brothers Schlagintweit, distinguished explorers of the highlands 
of Asia, the effects of diminished pressure upon the human 
organism are : " Headache, difficulty of respiration, and affec- 
tions of the lungs, — the latter even proceeding so far as to 
occasion blood-spitting, — want of appetite, and even nausea, 
muscular weakness, and a general depression and lowness of 
spirits. All these symptoms, however, disappear in a healthy 
man almost simultaneously with his return to lower regions." 
A singular observation was made by these travelers on the effect 
of motion of the air upon the symptoms described. They say: 
" The effects here mentioned were not sensibly increased by 
cold, but the wind had a most decided influence for the worse 
upon the feelings When occupied with observa- 
tions, we took very little, if any, bodily exercise, sometimes for 
thirty-six hours ; it would frequently occur nevertheless, even in 
heights not reaching 17,000 feet (about 5150 metres), that an 
afternoon or evening wind would make us all so sick as to take 
away every inclination for food. No dinner was cooked; the 
next morning, when the wind had subsided, the appetite was 
better. 

" The effects of diminished pressure are considerably aggra- 
vated by fatigue. It is surprising to what degree it is possible 
for exhaustion to supervene ; even the act of speaking is felt to 
be a labor, and one gets as careless of comfort as of danger. 
Many a time our people — those who ought to have served us as 
guides — would throw themselves down upon the snow, declaring 

1 Realencyclopaedie d. ges. Heilk., v., p. 529. 

* MM. Siveland Croce-Spinelli, two aeronauts, lost their lives in this manner during an 
ascent from Paris, in April. 1875. 



10 TEXT-BOOK OF HYGIENE. 

they would rather die upon the spot than proceed a step 
farther."^ 

These symptoms disappear when persons are exposed to 
these conditions for a prolonged time. Thus, in the Andes 
there are places 4000 metres above sea-level which are per- 
manently inhabited ; and in the Himalayas there are villages 
at a height of over 5000 metres constantly occupied. In this 
country, Pike's Peak, 4350 metres above the sea, has been 
occupied since 1873 by observers of the signal service. The 
men seem to become acclimated, as it were, and suffer little or 
no inconvenience from the diminished pressure after a time. 

The minor disturbances of healthy function produced by 
diminished pressure (within the limits of 4000 metres altitude, 
or 460 millimetres barometric pressure) are an increase in the 
pulse and respiration rate. This is probably due to the struggle 
of the organism to take up the required quantity of oxygen 
which is reduced in proportion by the rarefaction of the air. 
For example, the proportion of oxygen at a pressure of 460 
millimetres would be equivalent to 12.6 per cent, at sea-level, 
instead of the normal 20.9 per cent. 

Paul Bert has shown by personal experiments in the 
pneumatic chamber that the increase in pulse and respiration 
rate is not due to the merely mechanical diminution of pressure, 
but to the deficiency of oxygen. Hence the physiological effects 
of high altitudes upon circulation and respiration are not purely 
physical, due to diminished pressure, but vital, and depend upon 
the change in the chemical composition of the atmosphere. 
The simple diminution of oxygen without reduction of pressure 
will produce similar though not identical effects upon the 
organism. 

Above the height of 4000 metres above sea-level (below 
460 millimetres pressure) the profounder disturbances of func- 
tion characterized as " mountain sickness " come on. Different 



^ Results of a Scientific Mission to India and High Asia. By Hermann, Adolplie, and 
Robert De Schlagintweit, vol. ii, pp. 484, 485. 



I 



INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE. 11 

individuals react in different degree to the morbific influences of 
greatly diminished atmospheric pressure (and coincident reduc- 
tion of oxygen). Thus Glaisher reached an elevation of 11,000 
metres (191.1 millimetres pressure) and returned to the earth 
alive, while Croce-Spinelli and Sivel perished at the considerably 
lower elevation of 8000 metres, equivalent to a pressure of 260 
millimetres (7.2 per cent, of oxygen). 

The sanitarian is most concerned about the effects of press- 
ure of the atmosphere from 760 millimetres down to 460 milli- 
metres (or up to an altitude of 4000 metres above sea-level). 
The climatotherapy of various diseases requires that the effects 
of variations of pressure between these limits should be carefully 
studied. The observations of Mermod and Jourdanet^ have 
illustrated the common physiological effects of these circum- 
scribed changes, while the experiences of therapeutists have 
established the fact very clearly that many cases of phthisis 
improve markedly in a rarefied atmosphere. Other observers 
have also shown that the effects of diminished pressure are not 
always beneficial, and Dr. Loomis has warned against the send- 
ing of patients with heart disease to high altitudes. Whether 
the lethal effects that have been recorded in such cases are due 
to the increased activity of the heart and heightened blood- 
pressure from deficient oxygen, or as suggested by Dr. F. Don- 
aldson, Jr., to dilatation of the heart- walls from diminution of 
external pressure, is as yet unsettled.^ 

It is probable that the diurnal or accidentaP oscillations of 
barometric pressure at sea-level have no appreciable influence 
upon the organism. The statement is occasionally met that 
patients subjected to grave surgical operations oftener do badly 
during low atmospheric pressure, and some surgeons never 

* Jourdanet states that while the French and Belgian soldiers in Mexico had an accel- 
erated pulse, the natives had a normal pulse. In Mermod's observations the average frequency 
of the pulse at St. Croix (1106 metres above sea-level) was nearly four beats greater than at Strass- 
burgh (142 metres). The condition of the natives at the high settlements of the Andes and Hima- 
layas has not yet been investigated with exactitude. 

' American Climatological Association, l!:87, 

' Meaning the oscillation produced by storm waves. 



12 TEXT-BOOK OF HYGIENE. 

operate when the barometer is low or faUing if they can avoid 
it. An inquiry undertaken by the writer in 1876, in which the 
excellent records of the Massachusetts General Hospital and the 
observations of the Boston station of the United States Signal 
Service for five years were used as the basis of comparison, 
resulted negatively. The deaths following operations done on 
days when the barometer was high or rising were exactly equal 
in number to those following operations when the barometer 
was low or falling. Unfortunately, the investigation was never 
pursued to the extent of including other meteorological elements, 
such as humidity, cloudiness, precipitation, etc. The numerous 
studies of the relations of variations of pressure to the progress 
of infectious diseases have also failed to yield any fruits of value. 
Whether the nerve-pains so frequently complained of, especially 
by elderly patients, during the progress of areas of low barometer, 
are due to the diminished pressure, or to the influence of some 
other meteorological factor, such as humidity or electrical con- 
dition, cannot yet be decided. 

Increased atmospheric pressure, as noticed in caissons, tun- 
nels, and mines, produces increase in frequency and depth of 
respiration, diminution in the number of beats and volume of 
the pulse, pallor of the skin, increase of perspiration (although 
Smith states that this is only apparent and due to lack of evapo- 
ration from the surface), increased appetite, and more abundant 
excretion from the kidneys. 

Among the distinctly pathological effects of increased at- 
mospheric pressure are rupture of the drum of the ear, pain in 
the frontal and maxillary sinuses, neuralgic pains, nausea, some- 
times vomiting and local paralyses. Dr. A. H. Smith ^ defines 
this collection of symptoms as " The Caisson Disease," and gives 
the following summary of its characteristic features : — 

"A disease depending upon increased atmospheric pressure, 
but always developed after the pressure is removed. It is char- 

» The Physiological, Pathological, and Therapeutical Effects of Compressed Air p 47. 
Detroit, 1886. 



INFLUENCE OF CHANGES OF ATMOSPHERIC PRESSURE. 13 

acterized by extreme pain in one or more of the extremities, and 
sometimes in the trunk, and which may or may not be associated 
with epigastric pain and vomiting. In some cases the pain is 
accompanied by paralysis more or less complete, which may be 
general or local, but is most frequently confined to the lower 
half of the body. Cerebral symptoms, such as headache and 
vertigo, are sometimes present. The above symptoms are con- 
nected, at least in the fatal cases, with congestion of the brain 
and spinal cord, often resulting in serous or sanguineous effu- 
sion, and with congestion of most of the abdominal viscera." 



INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. 

Many of the derangements of health ascribed to high tem- 
perature are to a considerable degree due to other factors, promi- 
nent among which are high humidity, intemperance, overwork, 
and overcrowding. There can be little doubt, however, that the 
importance of the high temperature itself can hardly be over- 
rated. It has been generally accepted heretofore that a high 
temperature, together with a high relative humidity, is most 
likely to be followed by sun-stroke. A careful comparison in a 
series of deaths from sun-stroke in the city of Cincinnati in the 
summer of 1881 shows, however, conclusively that a very high 
mean temperature with a low relative humidity is more liable to 
be foUow^ed by sun-stroke than the high temperature when ac- 
companied by a high humidity. The same series of observa- 
tions also shows that the number of deaths was greater on clear 
days than on cloudy or partly cloudy days.^ A corroboration 
of this result is found in the fact that sun-strokes very rarely 
occur on shipboard, at sea, where the relative humidity is 
always high. 

The direct influence of the sun's rays upon the skin pro- 
duces at times an erythematous affection which may run into a 

* The Sun-stroke Epidemic of Cincinnati, O., during the Summer of 1881. A. J. Miles, 
Public Health, vol. vii, pp. 293-30i. 



14 TEXT-BOOK OF HYGIENE. 

dermatitis if the insolation is prolonged. Artificial heat may 
produce similar effects. 

Diarrhoeal diseases, both of adults and children, are much 
more frequent during hot than cold weather (and in hot than in 
cold climates), but it is probable that other factors aid in the 
production of these diseases besides the high temperature. 

Certain epidemic diseases are likewise more frequent in, or 
exclusively confined to, hot climates. These are cholera, yellow 
fever, and epidemic dysentery. Elephantiasis and the prevalence 
of certain skin diseases seem also to have some connection with 
a constantly high external temperature. The intimate relation 
between cause and effect is not clearly understood, although the 
belief is current that the origin and spread of such diseases 
depend upon the development of various parasitic organisms. 

Regarding the morbific effects of continued high tempera- 
tures, it is probable that an appropriate mode of life, proper 
diet, and suitable clothing would avert many of the bad conse- 
quences. Nevertheless, the fact remains that certain tropical or 
hot-weather diseases must be considered as primarily dependent 
upon high temperature, although the pathological effects may be 
due to an intermediate factor. It is not improbable that micro- 
organisms will be found to explain yellow fever, cholera infan- 
tum, and tropical dysentery. Cholera has already been shown 
to depend upon a pathogenic organism. In this case the high 
temperature is one of the associate but none the less indispens- 
able factors in the production of the disease. 

Extreme low temperature, as observed in the arctic regions, 
seems to produce a progressive deterioration of the blood 
(anaemia), in consequence of which most natives of temperate 
regions who are compelled to remain in the far north longer 
than two winters succumb to various haemic diseases, scurvy be- 
ing the most prominent. It is not improbable, however, that the 
dietary furnished is responsible for a large share of the evil 
effects ascribed to cold. The absence of sunlight for a consider- 
able part of the winter season may also have much to do with 



INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. 15 

the bad infliiences for which the low temperature is held 
responsible. 

Among the acute effects of great cold, frost-bite is the most 
frequent as well as the most serious. Loss of portions of the 
nose, or ears, or even of entire members are not infrequent 
results of frost-bite. 

In the arctic regions one of the most annoying aifections 
which the traveler has to contend against is snow-blindness, a 
severe ophthalmia produced by the glare of the snow. Neutral 
tinted glass goggles should be worn as a preventive.^ 

Dr. Henry B. Baker ^ has placed upon record a large mass 
of observations which appear to indicate that most of the acute 
diseases of the respiratory organs are caused by a low tempera- 
ture in conjunction with a low absolute humidity. Dr. Baker 
furnishes numerous diagrams, which seem to demonstrate that 
the curves for influenza, tonsillitis, croup, bronchitis, and pneu- 
monia are in general outlines all practically the same, and that 
they follow the curve for atmospheric temperature with surpris- 
ing closeness, rising after the temperature falls and falling after 
the temperature rises. He claims that this sameness indicates 
that the controlling cause is one and the same for all of these 
diseases, and that, directly or indirectly, the atmospheric tem- 
perature is that cause. They are diseases of the air-passages, 
and may be supposed to be influenced or controlled by the at- 
mosphere which passes through them. Although the curves are 
all similar, yet their difl'erences still further support his view, 
because the order of succession of the several diseases is such 
as would be expected if caused in the manner which he sup- 
poses. Thus croup and influenza precede in time bronchitis 
and pneumonia ; the curve for bronchitis shows that disease to 
respond quicker than does pneumonia to the rise and fall of the 



* See Payer's Narrative of the Austrian Arctic Voyage of 1872-74, pp. 250-3 and 317, for an 
account of the effects of cold on the organism, and on the best prophylactic measures to be 
adopted. The Report of the Surgeon-General of the U. S. Navy for 1880 also contains (pp. 350-8) 
a valuable memorandum by Ex-Surgeon-General Philip S. Wales, on Arctic Hygiene. 

2 Trans. Ninth International Med. Congress, vol. v. 



16 TEXT-BOOK OF HYGIENE. 

temperature. He suggests that the explanation of the causa- 
tion of these diseases has not been grasped before because one 
of the principal facts has not been apprehended, namely, the 
flict that cold air is always dry air ; on the contrary, it has been 
generally stated that when these diseases occur the air is cold 
and damp. He explains that while the cold air is damp rela- 
tively it is always dry absolutely, and he thinks that its bad 
effects on the air-passages are mainly through its drying effects, 
-which can best be appreciated by reflecting that each cubic foot 
of air inhaled at the temperature of zero, F. [— 17.8° C], can 
contain only J grain of vapor [1.33 gi-ammes per cubic metre], 
while when exhaled it is nearly saturated at a temperature 
of about 98° F. [36.5° C], and therefore contains about 18 J 
grains of vapor [about 43 grammes per cubic metre], about 18 
grains of which have been abstracted from the air-passages. 
Thus cold air falling upon susceptible surfaces tends to produce 
an abnormal dryness which may be followed by irritation and 
suppuration. He claims that coryza is sometimes so caused. 
Under some conditions the nasal surfaces are not susceptible to 
drying, the fluids being supphed in increased quantity to meet 
the increased demand made by the inhalation of cold air. In 
that case an unusual evaporation of the fluid leaves behind an 
unusual quantity of non-volatile salts of the blood, such as 
sodium chloride, and an unusual irritation results ; he thinks 
influenza is the name commonly given to this condition. The 
effects which the inhalation of cold air has on the bronchial 
surfaces depend greatly upon how the upper air-passages have 
responded to the increased demand for fluids ; because, if they do 
not supply the moisture it must be supplied by the bronchial 
surfaces, in which case bronchitis results. Finally, if the de- 
mands for moisture made by cold air are not met until the air- 
cells are reached pneumonia is produced. 

These claims are partly supported and partly opposed by 
an elaborate paper by Dr. J. W. Moore. ^ According to the 

» The Seasonal Prevalence of Pneumonic Fever, Trans. Ninth internat. Congress, vol v. 



INFLUENCE OF CHANGES OF TEMPERATURE ON HEALTH. 17 

statistics furnished by this writer, bronchitis and pneumonia 
show a remarkable contrast as to seasonal prevalence. The sta- 
tistics of London and Dublin agree very closely upon this point. 
Bronchitis falls to a very low ebb in the third or summer quarter 
of the year (July to September, inclusive), when only 12 per 
cent, of the deaths annually caused by this disease take place 
in Dublin and only 11 per cent, in London. In the last or 
fourth quarter (October to December, inclusive) the percentage 
of deaths from bronchitis rises to 27 in Dublin and 30 in London. 
The maximal mortality occurs in the first quarter (January to 
March, inclusive), when it is 38 per cent, in both London and 
Dublin. In the second or spring quarter (April to June, inclu- 
sive) the bronchitic deaths decline to 23 per cent, m Dublin and 
21 per cent, in London. 

The mortality from pneumonic fever is differently distrib- 
uted throughout the year. In the summer quarter more than 
14 per cent, of the annual deaths referable to the disease are 
recorded in Dublin and more than 15 per cent, in London. 
In the first quarter the figures are — London, 31 per cent.; 
Dublin, 31 per cent. In the second quarter they are — London, 
26 per cent. ; Dublin, 30 per cent. In the fourth quarter they 
are — London, 27 per cent. ; Dublin, 24 per cent. 

It therefore appears that the prevalence and fatality of pneu- 
monic fever from season to season do not correspond with the 
seasonal prevalence and fatality of bronchitis. The latter dis- 
ease increases and kiUs in direct relation to the setting in of cold 
weather ; it subsides in prevalence and fatality with the advance 
of spring and the advent of summer. Pneumonic fever, on the 
other hand, increases less quickly in winter and remains more 
prevalent in spring than bronchitis ; its maximal incidence coin- 
cides with the dry, harsh winds and hot sunshine of spring, 
when the diurnal range of temperature also is extreme. 

Dr. Moore believes that acute bronchitis is produced directly 
by the influence of low temperature, while pneumonia requires 
an additional cause, which he supposes to be a specific micro- 
organism. 2 



18 TEXT-BOOK OF HYGIENE. 

HUMIDITY OF THE ATMOSPHERE AS CONNECTED WITH CHANGES IN 

HEALTH. 

The propagation of certain acute infectious diseases is be- 
lieved to be due to a high relative humidity. There can be no 
longer any doubt that a very humid soil and air, especially if 
connected with a variable temperature, are almost constant 
factors in the production of pulmonary phthisis. Recent experi- 
ence in this country and abroad has shown that the high plateaus 
and mountains, far inland, where the soil is dry and the relative 
humidity of the air low, are the best resorts for consumptives. 

Of the effects of excessively dry air on health little definite 
is known. It seems probable, however, that catarrhal affections 
of the respiratory mucous membrane are more frequent in a dry 
than in a humid climate.-^ 

THE SANITARY RELATIONS OF AIR-CURRENTS. 

Primarily, winds or air-currents may be considered as favor- 
able to health. By the agitation of the air ventilation is secured, 
foul air removed from insanitary places, and diluted by ad- 
mixture of purer air. But air-currents may also be regarded as 
either directly or indirectly unfavorably influencing health. 
Vertical currents rising from the ground may carry morbific 
germs or viruses and give rise to disease. Horizontal currents 
or winds proper may also be the direct or indirect cause of de- 
rangements of health. 

Full credit is given by the public to cold winds and draughts 
in producing catarrhs and rheumatic pains. The progression of 
certain infectious diseases, especially malaria, is believed with 
good reason to stand in a definite relation with the direction of 
the wind. 

Certain local winds are known to have a deleterious effect 
upon living beings, especially when the latter are in bad health. 
Among these winds is the mistral^ a cold, dry, parching north- 

* See ante. 



SANITARY RELATIONS OF AIR-CURRENTS. 19 

west wind which blows along the Gulf of Lyons. It brings on 
rheumatism and muscular pains, and is said to excite pleurisy 
and pneumonia and l^o act unfavorably upon consumptives. 

The hora is a cold, dry wind coming down from the Alps 
and continuing across the Adriatic. 

The Texan northers are well known in the south westeiii 
part of the United States. They are extremely dry, and are 
often accompanied by a sudden fall of temperature. Changes 
of 28° C. (50° F.) within twelve hours are not infrequent in 
Western and Central Texas. Both man and beast suffer in- 
tensely from the cold, parching character of the wind. 

The sirocco of Northern Africa, Sicily, and Southern Italy 
has a world-wide notoriety for its depressing effect upon human 
energy. The liarmattan is equally noted on the west coast of 
Africa. It is hot and dry, while in Southern Europe the sirocco 
is hot and moist. 

The simoon is a hot, scorching wind of India, and is said 
to be deadly in its effects upon vegetation and extremely dele- 
terious to men and animals who are encountered by it. In 
Australia and South Africa hot winds are said to occur which 
completely destroy vegetable life in their track, and are often 
unwholesome in their effects upon animal life. 

The evil reputation of the Alpine folin is very well known, 
and neither native nor traveler is anxious to encounter it. It is 
warm and dry. 

With reference to the influence of electrical conditions of 
the atmosphere upon health, no observations have been made 
which justify definite conclusions.^ 

Mr. Alexander Buchan and Dr. Arthur Mitchell have 
analyzed the influence of the weather and season upon the 

* Dr. S. Weir Mitchell has shown, from the record of the case of Captain Catlio, U. S. A 
(American Journal Med. Sci., April, 1877, and N. Y. INIed. Jour., August 25 and September 1, 1883), 
that attacks of neuralgia — in this case, at all events— accompanied the progress of storms across 
the continent. Also, that the periods of maximum pain occurred with a high but falling barom- 
eter and increasing absolute humidity. There seems also to be some relation in this case between 
the maximum pain and the maximum magnetic force as shown by the declinometer. Dr. 
Mitchell's papers are among the most valuable positive contributions to hygienic meteorology, 
and deserve careful study. 



20 TEXT-BOOK OF HYGIENE. 

causation of disease, or, rather, upon the mortaUty from various 
diseases.^ Taking the records of the city of New York from 
1871 to 1877, it appears that the maximum number of deaths 
from small-pox occurred in May, the minimum in September. 
From measles there were two annual maxima and minima, the 
greater in July and September and the smaller in February and 
April. From scarlet fever the maximum was in April, the mini- 
mum in September. From typhoid fever the maximum was 
from August to November, the minimum almost equally distrib- 
uted throughout the rest of the year ; from diarrhoea, the maxi- 
mum in July and August, the minimum from December to 
March ; from diphtheria, the maximum in December, the mini- 
mum in August ; ^ from whooping-cough, maximum in Septem- 
ber and February, minimum in November and June ; for croup 
the curves agree pretty closely with the diphtheria curves ; from 
phthisis, the maximum in March, minimum in June. 

The following charts, reproduced by permission of the 
Massachusetts State Board of Health from the report of that 
body for 1888, show an almost identical movement of the 
mortality from different diseases throughout the year. They 
exhibit the reported mortality for 1888 and also for the six years 
from 1883 to 1888. 

From suicide, curiously, the greater number of deaths occurs 
in May, the smallest in February. This is contrary to the usual 
supposition that gloomy weather predisposes to suicide. The six 
summer months — from April to September — show a much larger 
number of self-murders than the remaining half-year. In eleven 
years, ending 1880, there were 1521 cases of self-destruction in 
New York. Of these 341 occurred during January, February, 
and March; 417 during April, May, and June; 412 during 
July, August, and September; and 351 during the last three 
months of the year. In Philadelphia, the results of examination 

1 Journal Scottish Meteorological Society, 1876-78. (Abstract in Richardson's Prevent- 
ive Medicine, p. 533 et seq. Philadelphia, 1884.) 

2 See paper on the Relation of Weather to Mortality from Diphtheria in Baltimore, 
by Richard Henry Thomas, in Trans. Med, and Chir. Faculty of Maryland, 1883. 



INFLUENCE OF SEASON UPON MORTALITY. 



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26 TEXT-BOOK OF HYGIENE. 

of the statistics of suicide for ten years are almost exactly 
similar. Out of 636 cases of suicide, 78 occurred in May, 71 in 
August, 57 in December, 54 each in October, July, and April, 
52 in June, 49 in November, 44 each in December and Feb- 
ruary, 43 in March, and 36 in January.^ Dr. Lee is led to be- 
lieve tliat " a low barometric pressure, accompanied by a high 
therm o metric registry, with sudden fluctuations from a low to a 
high temperature, together with much moisture and prevailing 
southwest winds, might somewhat account for the frequency of 
self-murder in the spring and summer months." 

THE SANITARY RELATIONS OF CHANGES IN COMPOSITION AND OF 
IMPURITIES IN THE AIR. 

The average proportion of carbon dioxide in the atmosphere 
is from 3 to 4 parts in 10,000. Pettenkofer^ places the maxi- 
mum limit of carbon dioxide allowable in the air of dwellings 
at 7 parts in 10,000. It is probable that this limit is very fre- 
quently exceeded without serious consequences to health, if the 
air is not at the same time polluted by organic impurities, the 
products of respiration. Prof. William Pipley Nichols found 
the air in a school-room in Boston to contain eight times the 
normal proportion of carbon dioxide, while Pettenkofer found, 
also in a school-room, after the same had been occupied two 
hours, eighteen times the normal proportion, or 72 parts in 
10,000.^ While such an excess of this poisonous gas must 
unquestionably have an unfavorable influence upon health, it is 
probable that the most serious effects are due to the coincident 
diminution of oxygen and the pollution of the air by the prod- 
ucts of respiration which necessarily take place during respira- 
tion. Carbon dioxide alone may be present in the air to a much 
greater extent than above mentioned without causing any appre- 
ciable inconvenience. In the air of soda-water manufactories 



» Suicide in the City and County of Philadelphia during a Decade, 1872 to 1881, inclusive, 
by John G. Lee, Trans. Am. Med. Asso., vol. xxxiii, p. 425. 

' 2 Quoted in Buck's Hygiene and Public Health, vol. 1, p. 615. 
' See table in Buck's Hygiene and Public Health, vol. i, p. 612. 






SANITARY RELATIONS OF IMPURITIES IN THE AIR. 27 

there is frequently as large a proportion as 2 per cent, of this 
gas present without producing any ill effects upon those breathing 
such an atmosphere. 

The amount of carbon dioxide in the atmosphere is greatest 
at night. It is also greater very near the ground tlian at a dis- 
tance of several feet above it. As carbon dioxide is absorbed 
!by the leaves of plants during the day-time, but given off at 
^night, the difference may partly be thus accounted for. Accord- 
ing to Fodor/ the source of a large proportion of the carbon 
dioxide in the air is the decomposition going on in the soil. 
This accounts for the larger percentage of carbon dioxide near 
the ground. This would also explain the variation of the pro- 
portion of carbon dioxide in the air under different meteoro- 
logical conditions. For example, it is found that during rainy 
weather the carbon dioxide in the air is diminished. This is 
accounted for partly by the absorption of the carbon dioxide 
by the saturated ground, while at the same time the porosity 
of the soil is diminished and the escape of the ground-air 
prevented. 

Mr. E.. Angus Smith made a number of experiments upon 
himself to determine the effects of an atmosphere gradually 
becoming charged with the products of respiration and per- 
spiration. His experiments were conducted in a leaden cham- 
ber holding 5 cubic metres of air. This air was not changed 
during the experiment. After remaining for an hour in this 
chamber, an unpleasant odor of organic matter was perceptible 
on moving about. The air, when agitated, felt soft, owing, 
doubtless, to the excess of moisture contained in it. The air 
soon became very foul, and, although not producing any dis- 
comfort, the experimenter states that escape from it produced a 
feeling of extreme pleasure, like " that which one has when 
walking home on a fine evening after leaving a room which has 
been crowded." ^ 

* Hygienische Untersucliungen ueber Luft, Boden und Wasser, Braunschweig. 1882, 
2te Abth. 

" Air and Rain, p. 138. 



28 TEXT-BOOK OF HYGIENE. 

Hammond ^ confined a mouse in a large jar in which were 
suspended several large sponges saturated with baryta water, to 
remove the carbon dioxide as rapidly as formed. Fresh air was 
supplied as fast as required. The aqueous vapor exhaled was 
absorbed by calcium chloride. The mouse died in forty-five 
minutes, evidently from the effect of the organic matter in the 
air of the jar. The presence of this organic matter was demon- 
strated by passing the air through a solution of potassium per- 



manganate. 



3 



The horrible story of the "black hole" of Calcutta 
familiar to every one. Of 146 prisoners confined in a dark ce 
at night, 23 were found alive in the morning. Among the sur- 
vivors a fatal form of typhus fever broke out, which carried off 
nearly all of them. After the battle of Austerlitz 300 prisoners 
were crowded in a prison ; 260 died in a short time from inhaL 
ing the poisoned air. Numerous other similar examples of the 
effects of polluted air are recorded. 

Usually the effects of foul air are not so sudden and strik- 
ing. In most instances, especially where the pollution has no 
reached a high degree, there simply results a general deficienc] 
of nutrition, which manifests itself in anaemia, loss of vigor of 
body and mind, and a gradual diminution of resistance to 
disease. 

It seems to be beyond question that persons who are con 
stantly compelled to inhale impure air, especially if combine! 
with an improper position of the body or lack of sufficient or 
appropriate food, furnish a very large percentage of chronic pul- 
monary affections. Phthisical patients, in the overwhelming 
majority of cases, are drawn from the classes whose occupations 
keep them confined in close rooms. Want of exercise and of 
good food doubtless aid in the development of the lung disease! 
Formerly, when less attention was paid to the proper construe^ 
tion and ventilation of barracks and prisons, the mortality from 

> A Treatise on Hyp;iene, with Special Reference to the Military Service, by William A. 
Hammond, M.D., Surgeon-General U. S. Army, p. 170. Philadelphia, 1863. 






I SANITARY RELATIONS OF IMPURITIES IN THE AIR. 29 

phthisis among soldiers and criminals was much greater than it 
j is now. In animals kept closely confined the same disease claims 
a large share in the mortality. 

Near the end of the last century over one-third of the in- 
fants bom in the old Dublin Lying-in Hospital died of epidemic 
diseases. After the adoption of an improved system of ventila- 
tion the mortality fell to about one-tenth of what it had pre- 
viously been. To illustrate the effect of similar conditions upon 
the health of domestic animals, the following instance is cited : 
Upward of thirty years ago a severe epidemic of influenza in 
horses appeared in Boston. At the instigation of Dr. H. I. 
Bowditch, every stable in the city was inspected, and classified 
as '• excellent," " imperfect," or " wholly unfit," in respect to 
warmth, dryness, light, ventilation, and cleanliness. It was 
found that in the first class fewer horses were attacked and the 
disease was milder, while in the third class every horse was 
attacked and the more severe and fatal cases occurred. 

Carbon monoxide is a very dangerous impurity often 
present in the air of living-rooms. Being an ingredient of 
illuminating gas, as well as the so-called coal-gas, which so 
frequently escapes from stoves and furnaces, its dangerous char- 
acter becomes apparent. Many persons die every year in this 
country from the inhalation of illuminating gas. People un- 
acquainted with the mechanism of the gas-fixtures frequently 
blow out the light instead of cutting off the supply of gas by 
tuniing the stop-cock. It is also a prevailing custom to keep 
the light burning " low " during the night. Any considerable 
variation of pressure in the pipes, or sudden draught, may put 
out the light and permit the gas to escape into the room, with 
fatal effect. Leaks in pipes or fixtures may have the same results. 

Coal-, coke-, or charcoal- fires may produce serious or fatal 
poisoning if the gas, which contains a large proportion of car- 
bon monoxide, is permitted to escape into the room.-^ In 

* See paper by Dr. John Graham in Transactions of Philadelphia College of Physicians 
for 1885. 



I 



30 TEXT-BOOK OF HYGIENE. |. 

certain parts of Europe, notably in France, the inhalation of the 
fumes of a charcoal fire is a favorite method of committing 
suicide. 

The gas which sometimes escapes from the stove when coal 
is burning has the following composition : — - 



Carbon dioxide, 6.75 per cent. 

Carbon monoxide, ..... 1.34 " 

Oxygen, 13.19 " 

Nitrogen, 79.T2 " 

Sulphuretted and carburetted hydrogen are not infrequently 
present in the air, especially about cess-pools and in mines and 
certain manufacturing establishments. Sulphuretted hydrogen 
is generally considered to be a violent poison, but there is no 
evidence that it is so unless oxygen is excluded. 

Carburetted hydrogen is the so-called "fire-damp" of 
mines, which is so often the cause of fatal explosions. Its in- 
halation does not seem to be especially noxious. It will be 
more fully referred to in a succeeding chapter. 

Variations in the proportion of ammonia present in the air 
are frequent. Its presence is an indication of organic decom- 
position in the vicinity, but nothing is known of the influence 
of the gas itself upon health, in the proportion in which it is 
ever found in the atmosphere. 

SEWER-AIR. 

Sewer-air, or sewer-gas, as it is often improperly called, is 
a variable mixture of a number of gases, vapors, atmospheric 
air, and solid particles, and is derived from the decomposition of 
the animal and vegetable contents of sewers. A number of 
analyses by different chemists have shown that the composition 
of sewer-air is extremely variable. The most important com- 
ponents, in addition to the constituents of atmospheric air, are : 
Carbon dioxide, ammonia, sulphuretted hydrogen, and a number 
of volatile organic compounds, which give to sewage its peculiar 
odor, but which are present in such small quantity as to prevent 



i 






SEWER- AIR. 31 

accurate determination by chemical means. Sewer-air may also 
contain particulate bodies, bacteria, and other microscopic or- 
ganisms, which are supposed by many to be the active causes 
of infectious diseases. Some recent researches by Carnelly and 
Haldane have shown that sewer-air usually contains a less 
number of micro-organisms than the external air of cities. The 
proportion of carbon dioxide found was also much less than was 
expected. When the contents of sewers remain in these re- 
ceptacles or conduits long enough to undergo decomposition, 
sewer-au' is always present. It is believed by some physicians 
and sanitarians that sewer-air is the direct cause of such diseases 
as typhoid fever, scarlet fever, diphtheria, and cholera, while 
others hold the view that the sewer-air is merely a favorable 
breeding-place for the germs of these diseases, and that it thus 
merely acts as a medium in which the infective agent grows, re- 
produces itself, and is conveyed from place to place. There is 
no absolutely trustworthy evidence in favor of either of these 
doctrines. 

It is hardly open to question, however, that the continual 
breathing of air polluted by emanations from sewers oflen pro- 
duces more or less serious derangements of health. Diarrhoea 
and other intestinal affections, mild cases of continued fever, and 
even cases of undoubted typhoid fever have been so frequently 
noted in connection with defective sewerage, and the escape of 
sewer-air into inhabited rooms, that doubt upon this point is 
hardly justifiable. With regard to typhoid fever, however, it is 
probable that the sewage in these cases contained the particular 
virus (bacillus 1) which, it is now generally believed, causes this 
disease. 

The effluvia from cemeteries, knackeries, and other places 
where the bodies of animals are undergoing decomposition, are 
popularly regarded as deleterious in their effects upon health. 
The evidence in favor of this view is, however, very indefinite. 

Professor Tyndall has shown ^ that even the apparently 

» Essays on Floating Matter of the Air. New York, 1882. 



32 TEXT-BOOK OP HYGIENE. 

clearest air is, when in motion, constantly filled with innumerable 
particles of dust, which are believed by many to give rise to 
various forms of disease. The presence of these particles can 
be easily demonstrated by means of the electric light. Every 
one has observed these minute particles in a bright ray of sun- 
light. Under ordinary conditions these particles of dust would, 
of course, give rise to no trouble, but, if intermingled with these 
dust-specks there were disease germs, — whether these germs be 
considered as living organisms, or as particles of dead tissue 
from the body, — then manifestly the inhalation of such "dust" 
would be dangerous.^ 

The quantity of dust found in the air of cities is much 
greater than in the country. Tissandier found that in Paris the 
percentage of dust was eight to twelve times greater than in the 
open country. One-fourth to nearly one-half of this atmos- 
pheric dust is organic, either animal or vegetable. Very recent 
observations have shown that in Paris the air contains nine or 
ten times as many bacteria in a given volume as the air at the 
observatory of Montsouris, just without the city. The relative 
proportions of organic and inorganic particles vary as 25 to 75 
in Paris, 45 to 56 in Dublin, and 25 to 75 in the open 
country. The organic particles are either particles of dead or- 
ganic matter, or minute organisms. The proportion of the 
latter varies in different seasons, being least in winter and 
spring, and greatest in summer and autumn. These organisms 
are not necessarily pathogenetic, but the conditions which favor 
the proliferation of non-pathogenic bacteria are likely to promote 
the development of disease-producing ones likewise. 

Among the pathogenic micro-organisms found in the at- 
mosphere are spores of achorion Schoenleinii, the so-called ma- 
laria bacillus of Klebs and Tommasi-Crudeli, and Fehleisen's 
erysipelas germ. It is probable, also, that the bacilli of tuber- 
culosis, cholera, and typhoid fever, and other organisms, at timea| 

1 See Chapter IX, on Industrial Hygiene, for effects of inhalation of dust in various 
industries. 



SEWER-AIR. 33 

undergo multiplication in the air, and that the latter may be the 
medium of communication of these diseases. But it must be 
admitted that our knowledge upon this point is at present 
rather vague and unsatisfactory. 

As regards the diseases that may be produced by the in- 
halation of pathogenic organisms there can be no doubt that 
diphtheria, glanders, measles, scarlet fever, whooping-cough, in- 
fectious pneumonia, and, above all, pulmonaiy tuberculosis, are 
so caused. It is likewise probable that yellow fever, epidemic 
influenza, cholera, and typhoid fever may be produced in this 
manner. 

TESTS FOR IMPURITIES IN THE AIR. 

The sense of smell will indicate the presence of sulphu- 
retted hydrogen, or of volatile organic matter. Chemical tests 
and the microscope will, however, be necessary to determine the 
presence of carbon dioxide, carbon monoxide, or suspended 
particulate matter in the air. 

In order to detect the presence of carbon dioxide, advantage 
is taken of the affinity of this compound for certain alkalies 
with which it forms insoluble compounds. If a stream of carbon 
dioxide gas is passed through lime- or baryta- water, an insoluble 
carbonate of lime or baryta is instantly formed, and produces a 
milky precipitate in the w^ater. If, instead of passing a stream 
of gas through the liquid, the latter be agitated with air con- 
taining carbon dioxide, a similar precipitate is produced. The 
most exact method of determining the amount of carbon dioxide 
in the air is that known as Pettenkofer's,^ but it is somewhat 
complicated. A readier method has been devised by Mr. Angus 
Smith, and is termed the minimetric test.^ A series of six wide- 
mouthed bottles, having a capacity respectively of 450, 350, 300, 
250, 200, and 150 cubic centimetres,^ is fitted with clean, tightly- 

*Lehrbucli der Hygene, Nowak. p. 149. 
» Op. cit., p. 152. 

» The equivalents in English measures are 14 ounces, 11 ounces, 9^ ounces, 8 ounces, 6J^ 
ounces, and 4% ounces. 



34 



TEXT-BOOK OF HYGIENE. 




§ 

as 
g ^ 

I 



T7 



fitting corks. The bottles are made perfectly clean and dry, 
and 15 cubic centimetres (3| drachms) of clear, fresh hme- or 
baryta- water put into the smallest, the cork replaced, and the 
bottle well shaken. If the water becomes turbid there is at 
least .16 per cent. (16 parts per 10,000) of carbon dioxide 
in the air treated. If only the water in the largest bottle 
becomes cloudy, the proportion of carbon dioxide is probably 
less than 5 parts in 10,000. For the intermediate series of 
bottles the amounts of carbon dioxide necessary to produce 
cloudiness are, respectively: For 200 cubic centi- 
metres of air, 12 parts in 10,000; for 250 cubic 
centimetres, 10 parts; for 300 cubic centimetres, 
8 parts; and for 350 cubic centimetres, 7 parts per 
10,000. If, therefore, a cloudiness is produced with 
any of the bottles except the largest, the amount 
of carbon dioxide present exceeds the standard 
allowable in pure air. The test should be frequently 
made, in order to acquire familiarity with its use. 
The same quantity of the test-liquid is, of course, 
used in each bottle. { 

A simple and easily-managed instrument, 
called an "air- tester," has been devised by Professor 
Wolpert, a distinguished German meteorologist. It 
is described as follows by Dr. S. W. Abbott, who 
first called attention to its merits in this country^: 
The little instrument consists of a simple rubber bulb 
(A) of a capacity of 28 cubic centimetres, a glass outlet-tube (B) 
with a constriction near its extremity (E). A glass test-tube, 
12 centimetres in length (C) and 2 millimetres in diameter, has 
a horizontal mark near the bottom, indicating the point to which 
it must be filled with perfectly clear lime-water, to contain 
3 cubic centimetres. The bottom of the tube is whitened and 
has a black mark stamped upon it (D). A small, wooden stand, 
a brush or swab, a vial of vinegar for cleaning the tube, and a 
bottle of clear lime-water complete the outfit. 

» Boston Med. and Surg. JournaL ; 



^m' 



Fig. 2. 
Air-Tester. 



TESTS FOR IMPURITIES IN THE AIR. 35 

In order to use the instrument, the lime-water (saturated 
solution) should be poured into the test-tube till it reaches the 
horizontal mark. Press down the bulb with the thumb, so as 
to expel the air within it as completely as possible, and allow it 
to fill with the air of the apartment, insert the small tube into 
the lime-water nearly to the bottom, and again expel the air 
with moderate rapidity, so that the bubbles may rise nearly to 
the top of the tube, but do not overflow, taking care to continue 
the pressure of the thumb till the small tube is removed from 
the lime-water. Repeat this process until the mark upon the 
bottom of the test-tube is obscured by the opacity produced by 
the reaction of the carbonic acid upon the lime-water, the observer 
looking downward through the lime-water from the top of the 
test-tube. 

With very foul air it is necessary to examine the mark after 
filling and discharging the bulb a few times only ; with good air, 
it must be filled twenty-five times and upward. 

The bulb represented in the cut is made a little larger than 
the required capacity, since a small amount of residual air 
usually remains in the bulb and cannot be expelled without 
great care. 

After each observation, the test-tube must be washed out 
and wiped dry. If a white incrustation forms upon the tube, it 
may be easily removed with a little vinegar, after which the 
tube should be thoroughly washed with pure water and dried. 

If the mark becomes obscured after filling the bulb ten or 
fifteen times only, the air of an apartment is unfit for continuous 
respiration. 

In a sick-chamber the air should be so pure that the tur- 
bidity of the lime-water will not render the mark invisible until 
thirty or forty fillings are made. 

The instrument should be used by daylight, over a white 
ground, as a sheet of writing-paper, and care should be taken 
not to vitiate the result by the observer's own breath. 

The following approximate table is taken from the article 



36 



TEXT-BOOK OF HYGIENE. 



I 



by Professor Wolpert, the first column representing the number 
of filUngs of the bulb, and the second column the parts per 
10,000 of carbon dioxide in a given sample of air: — ^ 



Number of 


Carbon Dioxide 


Number of 


Carbon Dioxide 


Number of 


Carbon Dioxide 


Fillings. 


per 10,000. 


Fillings. 


per 10,000. 


Fillings. 


per 10,000. 


1 


200. 


21 


9.5 


41 


4.9 


2 


100. 


22 


9.1 


42 


4.8 


3 


67. 


23 


8.7 


43 


4.6 


4 


50. 


24 


8.3 


44 


4.5 


5 


40. 


25 


8. 


45 


4.4 


6 


33. 


26 


7.7 


46 


4.3 


7 


29. 


27 


7.4 


47 


4.2 


8 


25. 


28 


7.1 


48 


4.1 


9 


22. 


29 


6.9 


49 


4.1 


10 


20. 


30 


6.6 


50 


4. 


11 


18. 


31 


6.4 


51 


3.9 


12 


16. 


32 


6.3 


52 


3.9 


13 


15. 


33 


6.L 


53 


3.8 


U 


14. 


34 


5.9 


54 


3.7 


15 


13. 


35 


5.7 


55 


3.7 


16 


12.5 


36 


5.5 


56 


3.6 


17 


12. 


37 


5.4 


57 


3.5 


18 


11. 


38 


5.3 


58 


3.5 


19 


10.5 


39 


5.1 


59 


3.4 


20 


70. 


40 


5. 


60 


3.3 



Carbon monoxide is detected by its reaction with palladium 
chloride, which gives a black color when brought in contact 
with the gas. If a strip of linen or blotting-paper be moistened 
with a solution of the palladium chloride (1 to 500) and sus- 
pended in air containing carbon monoxide, the black color will 
be developed. The suspected air may also be passed through a 
solution of sodio-chloride of palladium, when the liquid will 
turn black if carbon monoxide be present. 

The percentage of organic impurity in the air of an occu- 
pied room (products of respiration, etc.) is difficult to ascertain 
directly. 

Pettenkofer has found, however, that the proportion of 
carbon dioxide present is indirectly a measure of the organic 
impurity from respiration.^ As the determination of the carbon 



il 



TESTS FOR IMPURITIES IN THE AIR. 37 

dioxide is easy by the minimetric method of Angus Smith, or 
the ready method of Wolpert, the extent to which the air is 
polhited by respiratory impurities is readily ascertained. 

The presence of organic and other suspended impurities 
can be best demonstrated Avith a microscope. An objective, mag- 
nifying upward of 400 Unear diameters, and experience in the 
use of the instrument will be needed to obtain correct results. 
By moistening a glass slide with glycerin and exposing it in 
the suspected air, a sufficient quantity of the suspended matters 
may be collected in the course of twenty-four hours to permit 
some conclusions to be drawn from a microscopic examination.^ 

A common method of determining the presence or absence 
of a large quantity of carbon dioxide, for example, at the bottom 
of a well or privy-vault is to low^er a lighted candle to the 
bottom. If the light is extinguished, the air is considered irre- 
spirable ; but, if it continue burning brightly, the air is believed 
to be sufficiently pure to sustain life. Sulphuretted hydrogen 
and sulphide of ammonium are sometimes found in privy- vaults, 
and, although they will not extinguish a light, they speedily 
prove fatal if inhaled in a concentrated form, and to the exclu- 
sion of a sufficiency of oxygen. Cases have frequently occurred 
where serious or fatal results ensued from the presence of a dan- 
gerous gas, which was thought to be excluded by the burning 
candle. 

^ Recent observations in this country (see Annual Reports of the Surgeon. General of 
the XaTj- for 1879, pp. -15 and 46, and the same for 1880, pp. 31 to 3-i) seem to throw some doubt upon 
the entire reliability of this method of determining the amount of organic matter in the air 
examined. Prof. Ira Remsen (Report National Board of Health, 1879, p. 77, and 1880, p. 308 et 
seq.) has shown the insufficiency of the chemical methods at present in use, and points out the 
difficulties of making trustworthy and satisfactory determinations of organic matter in the air. 
The great technical difficulties of the various analytical processes render it unwise to burden 
these pages with a description of them. Only expert chemists are qualified to make a thorough 
air analysis, and the author does not feel competent to otfer advice to them. Dr. Cornelius B. 
Fox's book on '• Sanitary Examinations of Water, Air, and Food," and Fliigge's "Lehrbuch der 
Hygienischen Untersuchungsmethoden" contain detailed descriptions of the best methods 
employed. 

* Dr. G. M. Sternberg, U. S. A. (Report National Board of Health, 1880) , gives an ac 
count of his investigations into the suspended matters of the air. The question is also con- 
sidered in a practical manner by Surgeons Kidder and Streets, U, S. N., in Reports of the 
Surgeon-General of the Navy for 1880 and 1881. See also Bacteria, Sternberg and Magnin, 
2d ed., p. 197. 

» See a case reported in Philadelphia Medical Times, October 21, 1882. 



38 TEXT-BOOK OF HYGIENE. 

It is advisable in all cases to exhaust the stagnant air in 
old wells and privy-vaults before permitting any one to descend. 
Perhaps the readiest method of exhausting the vitiated air in 
such places would be to lower heated stones, masses of hot iron 
or pails of hot water, to near the bottom, which produce a rare- 
faction of the air and cause it to ascend. Its place will then be 
occupied by purer air from without. The rarefaction produced 
by the explosion of gun-powder has also been made use of with 
success ; but this has some objections, because the combustion 
of powder itself produces gases which are noxious if breathed 
in large quantity. An animal, such as a cat or dog, should be 
first lowered into the suspected well for fifteen or twenty min- 
utes, in order to determine whether the air at the bottom is 
capable of sustaining life, before permitting the workmen to 
descend. Similar precautions should be used in old, long- 
unused mines to prevent fatal efiects from the so-called " choke- 
damp," which is largely composed of carbon dioxide. 

PRINCIPLES OF VENTILATION. 

During ordinary respiration an adult human being adds 
900 grammes = 455,500 cubic centimetres (14 cubic feet) of 
carbon dioxide to, and abstracts 744 grammes = 516,500 cubic 
centimetres (16 cubic feet) of oxygen from, the atmosphere in 
twenty-four hours. Hence, if the individual were confined in 
an apartment where the inclosed air could not be intermingled 
by difi'usion with the atmosphere without, the proportion of 
carbon dioxide would soon become so great that the processes 
of life could not be sustained, and the individual would die. 
This result would be reached even sooner than the point here 
mentioned, for the organic matter exhaled from the lungs and 
the surface of the body would increase the poisonous condition 
of the air even more than the carbon dioxide given oiF. It is 
easily seen, therefore, how important the study of the principles 
and practice of ventilation becomes in hygiene. In this chapter 
only the principles underlying this subject can be definitely 



i 



PRINCIPLES OF VENTILATION. 39 

stated. Practical details will be more fully given in the chapters 
devoted to dwellings, schools, hospitals, etc. 

It is generally accepted among sanitarians that the presence 
of .07 per cent. (7 parts in 10,000) of carbon dioxide in the air 
indicates the greatest amount of organic impurity (from respira- 
tion or combustion) consistent with the preservation of health. 
As each individual gives off from his lungs, in the process of 
respiration, 316 cubic centimetres of carbon dioxide per minute, 
the diffusion in the air surrounding him must be sufficiently 
rapid to keep the air to be breathed at the standard of .07 per 
cent, above mentioned. 

Adopting this as the standard of maximum impurity allow- 
able, 90 cubic metres of fresh air per hour will be needed for 
each individual to keep him supplied with pure air. This is for 
a person in a state of health ; in cases of disease a more rapid 
change of air will be necessary to keep that surrounding the 
patient in a state of purity. 

Ventilation is defined by Worcester as " the replacement 
of noxious or impure air in an apartment, mine, or inclosed 
space by pure, fresh air from without." By Dr. Parkes the 
term is restricted to " the removal or dilution, by a supply of 
pure air, of the pulmonary and cutaneous exhalations of men 
and the products of combustion of lights in ordinary dwellings, 
to which must be added, in hospitals, the additional effluvia 
which proceed from the persons and discharges of the sick. All 
other causes of impurity of air ought to be excluded by cleanli- 
ness, proper removal of solid and liquid excreta, and attention 
to the conditions surrounding dwellings." ^ 

A proper system of ventilation must take into consideration 
the cubic space of the apartment or building to be ventilated, 
the number of persons ordinarily inhabiting this space, whether 
constantly or only temporarily occupied, and certain other col- 
lateral elements, such as the character of the building to be 
ventilated, its exposure, necessity for artificial heating, etc. 

1 Manual of Practical Hygiene, 6tli ed., New York, vol. i, p. 157. 



40 TEXT-BOOK OF HYGIENE. 

The amount of cubic space that must be allowed to each 
individual is determined by the rapidity with which fresh air 
must be supplied in order to keep that surrounding the indi- 
vidual at the standard of less than .07 per cent, of carbon dioxide. 
For example, in a space of 3 cubic metres, the air must be 
changed thirty times in an hour, in order to prevent the carbon 
dioxide exceeding the above proportion ; that is to say, to allow 
90 cubic metres of air to pass through that space in the time 
mentioned. This would create an uncomfortable, if not injurious, 
draught. If the space contained 30 cubic metres, the air would 
need renewal only three times an hour. 

A space of 15 cubic metres could be kept supplied with 
pure air without perceptible movement if all the mechanical 
arrangements for changing the air were perfect ; but such per- 
fection is rarely attainable, and hence there would be either 
draughts or insufficient ventilation in such a small " initial air- 
space," as it is termed. The initial air-space should, therefore, 
be not less than 30, or, better, 40 cubic metres. The air of this 
space could be changed sufficiently often to keep it at its standard 
of purity without creating unnecessary draught. For sick per- 
sons this should be doubled. In hospitals, therefore, the cubic 
air-space allowed to each bed should not be less than 60 to 80 
cubic metres. 

As stated, the purposes for which the building or apartment 
to be ventilated is employed requires differences in the cubic 
space and in the volume of fresh air supplied. Morin gives the 



I 



following table : — 




Table III. 






Fresh Air Required 




per Hour per Head. 


Hospital wards for ordinary cases, 


60-70 cubic metres. 


Hospital wards for surgical and obstet 




rical cases, .... 


100 " " 


Hospital wards for contagious diseases 


150 " " 


Prisons, . . . , c . 


. 50 " " 



PRIXCIPLES OF VENTILATION. 41 



"Workshops, 


(ordinar}" occupations, , 
(unhealthy, " 


60 cubic 
. 100 


metres. 

u 


Barracks, 


(during the day, 
\ '- '' night, . 


. 30 " 
, 40-50 " 


(( 
u 


Theatres, 


..... I 


. 40-50 " 


u 


Assemblj^ rooms for long receptions, , 


. 60 " 


u 


u 


" '' brief " 


. 30 " 


u 


Primary schools, .... 


. 12-15 " 


u 


Higher 


u 


. 25-30 " 


u 


Stables, . 




, 180-200 " 


il 



These figures are not excessive from a sanitary stand-point, 
although few buildings meet the requirements here set down. 

The source of the air supplied must, of course, be capable 
of }*ielding pure air. It should not be drawn from damp cellars 
or basements, or from the immediate vicinity of sewers or drains. 
Air taken from such places is little better for respiration than 
that which it replaces in the apartments to be ventilated. 

Ventilation may be accomplished either with or without 
artificial aids. In buildings or rooms, used as habitations, 
natural ventilation (with, perhaps, the simplest mechanical aids) 
is made use of almost entirely. In large buildings, such as 
churches, theatres, schools, or in ships and mines, one of the 
artificial systems must be adopted if efficient ventilation is 
desired. 

Natural ventilation takes place by diffusion, by perflation, 
and in consequence of inequality of atmospheric pressure. By 
diffusion is meant the slow and equable entrance of air from 
without and exit from within a room through the walls or ill- 
made joints without the influence of wind-currents. In an 
occupied room this is, however, insufficient to keep the air pure, 
because many of the organic impurities of respired air are mole- 
cular, and, therefore, incapable of making their way out of the 
rooms through the walls. 

Perflation means, literally, " blowing through," and, if the 
direction and force of air-currents could be regulated, this would, 
with simple mechanical arrangements, be an efficient means of 



42 TEXT-BOOK OF HYGIENE. 

ventilation. However, the uncertainty of the force and direc- 
tion of the wind makes this method of ventilation untrustworthy, 
except in warm weather. 

Unequal pressure between the air in a room and that 
without is, within certain limits, an efficient means of ventila- 
tion, and is usually relied upon in ordinary apartments. When 
the air in a room is heated above the temperature of the external 
air, either by a fire, lights, or by the presence of a number of 
persons in the room, it expands, and part of it finds its way out 
through numerous crevices and bad joints found in all buildings. 
The air which remains, being less dense than the external air, 
the latter enters the room by various openings, until the equality 
of pressure is re-established. But as the heating of the enclosed 
air continues, the process is momentarily repeated and becomes 
continuous. 

Although the impurities of respired air (carbon dioxide, 
organic matter) are heavier than the air itself at the same 
temperature, it is a familiar fact that the most impure air in an 
occupied room is always found near the ceiling, the impurities 
being carried upward with the heated air, and that the pure air 
from without, being colder, fills the lower part of the room. 

If the cold, outside air were to be admitted at the bottom 
of the room, and means allowed for the escape of the hot air at 
the top, the conditions of the old health-maxim, to " keep the 
feet warm and the head cool," would be reversed, This w^ould 
be no less uncomfortable than unwholesome. In all plans for 
natural ventilation, therefore, provision must be made to secure 
a gradual diffusion of the cold, outside air from above, or to 
have it warmed before it enters the room. With a large chimney 
as an aspirating shaft,^ with flues at the top and bottom of the 
room, and openings in the w^alls of the room near the ceiling to 
admit fresh air, sufficient ventilation can be usually secured in 
cold weather, in a room not overcrowded. 

* Of course thei'e is really no such thing as a real aspiration, or "sucking out" of the air 
through the chimney or so-called " aspirating shaft." The upward movement of the air in the 
Shaft is due to its displacement by the colder or denser air entering the room. 



i 



PRINCIPLES OF VENTILATION. 43 

When a room is heated by a furnace, the fresh ah* is warmed 
before it is introduced, and the foul air escapes either through a 
ventilating shaft, a ventilator in the window or wall, or through 
the numerous fissures and other orifices which defective car- 
pentering always leaves for the benefit of the health of the 
occupants. 

The following rules for the arrangement of a system of 
natural ventilation are modified and condensed from Parkes^: — 

The apertures of entrance and of exit for the air should be 
placed far enough apart to permit thorough diffusion of the 
fresh air. 

When the air is brought into a room through slits or tubes 
in the walls near the ceiling, the current should always be 
deflected upward by an inclined plane, in order to prevent a 
mass of cold air from descending over the shoulders of the 
occupants and chilling them. 

The air must be taken from a pure source. 

The inlet-tubes should be short, and so made as to be easily 
cleansed, otherwise dirt lodges and the air becomes impure. 

Inlets should be numerous and small, to allow a proper 
distribution of the entering air. 

Externally, the inlets should be partially, protected from 
the wind to prevent strong draughts ; they should also be pro- 
vided with valves to regulate the supply of air. 

If the air cannot be warmed, the inlets must be near the 
ceiling ; if it can be heated, it may enter near the floor. 

The air may be warmed by passing it through boxes con- 
taining hot water or steam coils, by passing it through chambers 
around grates or stoves, or heating it in a furnace. 

In towns or manufacturing districts the air should be 
filtered before allowing it to enter the room. Thin flannel or 
muslin spread over the openings answers very well as filtering 
material. 

Outlets should be placed at the highest point of the room 

* Manual of Practical Hygiene, 6tli ed., New York, vol. i, p. 177. 



44 TEXT-BOOK OF HYGIENE. 

and should be protected from the weather. An opening into the 
chimney near the ceihng will answer well in many cases. 

In one-story buildings, ridge-ventilators make the best out- 
lets. The entrance of snow and rain must be prevented by 
suitable arrangements. 

A small space or slit between the horizontal bars of the 
upper and lower window-sash will admit sufficient air in a proper 
direction in small rooms, even when the window is shut. 

In all rooms, howsoever ventilated, doors and windows 
should be often opened to permit a thorough flusliing of the 
interior with fresh air. 

For large buildings, hospitals, schools, theatres, ships, and 
mines two systems of artificial ventilation are in use. One 
operates by extracting the foul air by means of fans, the other 
by forcing in fresh air, allowing the impure air to find its way 
out as best it may. 

Further details upon the practical application of these prin- 
ciples will be given in succeeding chapters of this work. 

[In addition to the works mentioned in the text the follow- 
ing may be referred to as more fully treating of the subjects 
considered in this chapter : — 

Flammarion : The Atmosphere. — The Articles on Atmosphere and 
Climate in the Encyclopaedia Britannica, 9th edition. — Reports of the 
Chief Signal Officer of the Army. — A paper on Climate and Diseases, by 
Dr. Cleveland Abbe, in Report of Nacional Board of Health for 1880. — 
Die Canalgase, by Dr. F. Renk, Munchen, 1884. — Morin : On Warming 
and Ventilating Occupied Buildings ; translated in Smithsonian Report 
for 1873 and 1874.— Y. Pettenkofer nnd Ziemssen's Handbuch der Hy- 
giene, I Theil, 2 Abtheilung. Die Luft, by Dr. F. Renk.] 



CHAPTER II. 

Water. 

Physiologists teach that nearly two-thirds of the tissue of 
the animal body consists of water. Inasmuch as this water is 
constantly being lost by evaporation from the skin, exhalation 
by the lungs, and excretion through various organs, it is evident 
that the loss must be constantly supplied if the functions of life 
shall be properly performed. 

It appears probable that certain diseases are at times spread 
through the agency of insufficient or impure drinking-water. 
It is, therefore, a matter of very great importance to have a defi- 
nite notion of what constitutes a pure and sufficient supply of 
water, and how best to secure it, to be able to detect its condi- 
tions of purity and impurity, and to know how to maintain the 
former and avoid the latter. It will be necessary to consider in 
detail, therefore, the quantity of water required by each indi- 
vidual for the maintenance of health, the sources whence water 
is obtained, how it should be collected and stored to the best 
advantage, the impurities likely to be contained in it, and the 
methods of keeping it pure, or of purifying it when it has 
become polluted or vitiated in any manner. 

THE QUANTITY OF WATER REQUIRED BY HUMAN BEINGS. 

Dr. Parkes, after a number of experiments, concluded that 
a man of the English middle class, " who may be taken as a 
fair type of a cleanly man belonging to a fairly cleanly house- 
hold," uses about twelve gallons of water per day. This covers 
all the water needed, including a daily sponge bath. Dr. 
DeChaumont estimates^ that 16 gallons should be the daily 

» Parkes' Hygiene, 6th ed., New York, vol. i, p. 5. 

(45) 



46 TEXT-BOOK OF HYGIENE. 

allowance. By order of the British War Department, 15 gal- 
lons of water are allowed to each soldier daily. In very many 
instances this quantity cannot be furnished, but in such cases 
there necessarily results some deficiency in cleanliness. It is 
probable that among the poorer classes, especially where a large 
supply of water is not convenient, the quantity used is not over 
one-fourth of the above estimate. 

In estimating the daily supply of water needed in a com- 
munity, large or small, other circumstances must be taken into 
consideration in addition to the demands of the individual. 
For example, in towns or cities allowances must be made for 
animals, manufacturing purposes, probable waste, fires, sewerage, 
etc. In cities an allowance of 50 gallons daily per head would 
not be excessive. In most American cities the supply is much 
greater.-^ The present daily supply in Baltimore, which is de- 
rived from an excellent source, is estimated at 60 gallons per 
head, which could be increased to three times that quantity if 
necessary. 

A serious problem, affecting, however, the engineer rather 
than the sanitarian, is the prevention of waste of water in places 
where the supply is limited. It is estimated that in Chicago 
one-half of the water pumped is wasted through negligence and 
imperfections in the supply apparatus, while in St. Louis the 
annual cost to the city of the water that is wasted is placed at 
$400,000. It has been proposed to check this wanton waste by 
measuring the quantity of water used by each household by 
means of a meter, as the supply of gas is now measured, and 
this has been carried into effect in places. There are, however, 
serious objections to this method. One of the objections is that 
the very class of persons whom it is desired to induce to use a 
plentiful supply of water would, from motives of economy, use 
less than is necessary for cleanliness and health. A system of 
vigilant inspection of the water service in houses would probably 
serve to reduce this unnecessary waste to a considerable extent. 

» Buck's Hygiene and Public Health, vol. i, p. 214. 



SOURCES OF DRINKING-WATER. 47 

SOURCES OF DRINKING-WATER. 

All water, from whatever direct source obtained, comes 
originally, by precipitation, from the atmosphere. In many 
places the rain- or snow- water is the only source of supply. This 
is usually collected as it falls upon the roofs of buildings and 
conveyed by gutters and pipes to cisterns, where it is stored until 
needed. 

In Venice, the rain falling upon the streets and court- 
yards is also collected in cisterns after filtering through sand. 
The cisterns used for the storage of water in New Orleans and 
other Southern cities in the United States, where the tempera- 
ture rarely falls below the freezing-point, are generally con- 
structed of wood and placed above-ground. Farther north, 
where it is necessary to protect them against the action of frost, 
they are placed under-ground. These under-ground cisterns are 
usually built of brick. The water from cisterns above-ground 
becomes very much heated in summer, and necessitates the use 
of large quantities of ice to make it palatable. The water from 
the under-ground cisterns is pleasantly cool in summer, and is 
also guarded against freezing in winter. There are, however, 
very serious objections to storing drinking-water in under-ground 
cisterns. These reservoirs are usually placed within a few feet 
of privies and cess-pools, and, as neither the retaining walls of 
the cisterns nor those of the privies are water-tight, it often 
happens that the drinking-water becomes strongly impregnated 
with the soluble portions of the excrement, or the products of 
its decomposition, which have drained into the cistern. Per- 
sonal observations in Memphis in 1879, as well as the careful 
chemical analyses made afterward by Dr. Chas. Smart, U. S. A.,^ 
have con-^dnced the author that the objections to all under- 
ground cisterns built of brick, stone, or cement are insuperable 
from a sanitary point of view. Dr. Smart found over one-half 
of the under-ground cisterns examined by him in Memphis and 

» Report National Board of Health, 1880, pp. 437-441. 



48 TEXT-BOOK OF HYGIENE. 

other cities and towns to be leaky and presenting evidence of 
organic pollution. The water from 31 out of 80 cisterns ana- 
lyzed showed decided contamination by sewage. It would seem 
advisable to prohibit all under-ground cisterns for the storage of 
drinking-water unless they are constructed of iron, w^hich should 
be protected against oxidation by a thorough coating of coal- 
tar. Where any other system of collection and storage is avail- 
able, however, the under-ground cistern should be unreservedly 
condemned. 

E-ain-water collected in the country, away from manufac- 
turing districts, is usually quite pure and wholesome. Its taste 
is, however, flat and insipid, owing to absence of carbon dioxide 
and mineral constituents. In cities rain-water frequently con- 
tains such a large amount of organic matter and other impurities, 
which have been washed out of the air by the rain, that it may 
be unfit for drinking. On account of its softness, rain-water is 
very desirable for washing and other domestic purposes. If the 
statement made in the last chapter, concerning the presence of 
organisms in the atmosphere, is remembered, it will be evident 
on a moment's thought that such organisms, when contained in 
rain-water, may be the source of disease. The putrefaction 
which so readily takes place in rain-water upon standing a few 
days is caused by certain of the organisms carried down out of 
the lower strata of the air by the descending rain or snow. 

Precipitation is an exceedingly untrustworthy source of 
water, and should never be depended upon when other sources 
of supply are available. Water famines are frequent wherever 
people are compelled to rely upon such an uncertain source of 
supply as rain or snow. 

Rivers and smaller streams probably supply the larger 
number of cities and towns in this country with drinking-water. 
AVhen care is taken to prevent the pollution of the stream above 
the point whence the water is taken, this is usually of fair 
quality for domestic purposes. When the river can be tapped 
near its source, or before a large number of manufacturing 



SOURCES OF DRINKING-WATER. 49 

establishments can empty their waste products into its current, 
or before it receives the sewage of a considerable number of 
inhabitants living on its banks, the water can generally be re- 
garded as safe. It is very difficult, however, except in the less 
settled portions of the country, to find these favorable conditions 
present. 

Among the minor objections to the use of river-water for 
domestic purposes are the liability of most streams to become 
turbid in times of freshet, and the discoloration of the water 
from dissolved coloring-matters if the stream flows through a 
marshy or peaty region. These objections are, however, not 
serious, as filtration will readily remove the suspended matters. 
The coloring-matter is probably harmless. The organic matter 
contained in the water of some streams, even when pollution by 
sewage and manufacturing refuse is absolutely excluded, may, 
however, be the cause of disease. Dr. Smart has shown ^ that 
the water from streams in Nebraska, AYyoming, and Utah con- 
tained organic matter varying in amount from .16 to .28 parts 
per million.^ He thinks the so-called "mountain fever" of the 
Rocky Mountain region is a malarial fever caused by the large 
amount of organic matter in the drinking-water. 

Dr. G. M. Kober, U. S. A., states that he has frequently 
drunk water from mountain streams which had a perceptible 
taste of cattle-manure, and suggests that as the origin of the 
ammonia found by Dr. Smart in the water of mountain streams. 
Dr. Kober also regards the "mountain fever" as a typhoid fever 
with malarial complications.^ 

The most serious objection to the use of river- water for 
domestic purposes is the employment of streams as carriers of 
refuse from manufacturing establishments, or of the sewage of 
cities and towns. In Great Britain and some parts of the con- 
tinent of Europe, owing to the density of population and the 

, ^ American Journal Med. Sciences, January, 1878, p. 28 et seq. 

2 The source of this organic matter seems to be the melted snow which makes up a large 
portion of the streams. 

3 Report of California State Board of Health for 1886, pp. 48 and 177. 

4 



50 TEXT-BOOK OF HYGIENE. 

variety and extent of manufacturing industries, many of the 
streams are in an extremely filthy condition. In this country, 
too, especially in the more thickly settled manufacturing districts 
of New England, the pollution of rivers has increased to a 
degree to seriously jeopardize the health of the people who are 
compelled to draw their water-supply from such streams. Several 
years since a commission was appointed by the State Board of 
Health of Massachusetts to inquire into the extent of the pollu- 
tion of the streams in that State, and to devise means for pre- 
venting such pollution. The commission extended its inquiries 
and observations over several years, reporting the result to the 
State authorities at intervals.^ It was found that the water of the 
Blackstone River, at Blackstone, where it crosses the State line 
and enters Bhode Island, contained over 10 per cent, of sewage 
and refuse waters.^ Other streams in Massachusetts show 
similar pollution. That the presence of such excessive con- 
tamination renders the water unsuitable for domestic pur- 
poses must appear evident. It is probable, however, that the 
most dangerous of the polluting matters are the excreta of 
human beings, especially those of patients suffering from certain 
specific diseases, such as typhoid fever or cholera. 

Only a few years ago it was a generally-accepted theory 
that running-water, though polluted by sewage, "purified itself" 
after flowing a distance of twelve miles, and the comforting and 
reassuring doctrine is still held by many. Becent observations 
point to the conclusion, however, that the self-purification of 
rivers is not entirely to be relied upon. A certain proportion 
of the sewage, it is true, undergoes oxidation in the presence of 
light and air and minute organisms,^ and so becomes changed 
into other, possibly innocuous compounds. But at present it is 
not known what proportion or what kind of organic matter 
does undergo this change. Another portion of the impurities 
is deposited upon the bottom and sides of the stream, having 

» Reports State Board of Health of Massachusetts for 1873, 1874, 1876, 1877, 1878, 1879, 1880. 

3 Report State Board of Health of Massachusetts, 1876, p. 145. 

* Disinfection, in Eulonburg's Rcalencyclopa^die d. ges. Heilkunde, vol. iv, p. 68. 



SOURCES OF DRINKING-WATER. 51 

been only held in suspension, and not dissolved in the water. A 
portion probably forms chemical combinations with other sus- 
pended or dissolved matters, and is changed into compounds 
which may be volatile and pass off into the air, or form insoluble 
precipitates. 

The remainder is rendered less perceptible or imperceptible 
to chemical means by dilution. Every stream has sources of 
inflowing water — feeders — which increase its volume, and thus 
dilute any foreign admixture. 

In view of these facts, the theory of the self-purification 
of streams, as formerly held, can no longer be regarded as true. 
But it is unquestionably true that running-water does regain its 
purity if the inflow of sewage and other refuse is not excessive. 
It cannot be stated with confidence, however, when a stream, 
once polluted, becomes fit to use again. Moreover, as it is not 
possible, by any practicable chemical treatment or filtration on 
a large scale, to make a polluted water absolutely wholesome, it 
is safer not to use as a source of domestic supply a stream which 
is known to have been seriously contaminated by sewage matters 
or other impurities. 

The water from fresh- water lakes and ponds is generally to 
be preferred to river- water for domestic use. It is less liable to 
become turbid from time to time, and, except in the case of 
small ponds, inflow of sewage is not likely to cause fouling of 
the water to any serious extent. When the supply can be 
drawn from large lakes, as is done in Chicago and other cities 
on the great lakes of the United States, no purer or better source 
can be desired. In these cases the point whence the water is 
taken should be far enough from shore to avoid possibility of 
sewage contamination. When the water-supply is taken from 
small ponds, all sewage and waste products from houses and 
factories must be rigidly excluded ; otherwise, diseases attribu- 
table to the polluted water are likely to arise among those using 
the same. 

The water in small lakes and storage reservoirs sometimes 



52 TEXT-BOOK OF HYGIENE. 

becomes ofFensive in taste and odor. The water-supplies of 
several of the large Eastern cities have within the past seven or 
eight years at times had a peculiar odor and taste somewhat 
resembling cucumbers. After considerable study, Prof Ira 
Kemsen, of Baltimore, found the cause of this odor and taste 
in a minute fresh- water sponge, the S pong ilia fluviatills. A still 
more offensive odor, tersely described as the " pig-pen odor," is 
given to the water by the decay of certain species of nostoc and 
other algge. It is not known that either these vegetable or 
animal organisms, if present, render the water prejudicial to 
health. ■ 

Ponds are often used as sources of ice-supply. It was 
formerly supposed that in the process of freezing, solid matters 
in the water were not included in the block of ice when con- 
gelation occurred. Recent observations have shown the falsity 
of this assumption. In 1875, an outbreak of acute intestinal 
disease at Pye Beach, New Hampshire, led to an inquiry by 
Dr. A. H. Nichols, which disclosed the fact that the ice used 
contained a large percentage of organic matter.^ The use of 
ice from a different source was followed by an almost immediate 
disappearance of the disease. Upon further investigation it 
was discovered that the impure ice had been gathered from a 
small, stagnant pond into which a small brook carried large 
quantities of saw-dust from several saw-mills. The water of the 
pond was loaded with organic matter, and in summer the gases 
of decay arising from it were very ofFensive. Chemical exam- 
ination showed that the ice from this pond contained nearly 6 
parts of organic matter in 100,000, while in pure ice the organic 
matter amounted to only .3 part in 100,000. A similar inves- 
tigation into the character of the ice furnished to the residents 
of Newport, P. I., was made under the auspices of the Sanitary 
Protection Association of that city. The ice, which was cut 
from ponds in the immediate neighborhood of the city, was 
found to contain an excessive proportion of organic matter. 

» Report Massachusetts State Board of Health, 1876, p. 467. 



SOURCES OF DRINKING-WATER. 53 

Large quantities of sewage and other impurities were discharged 
into these ponds.^ 

A series of experiments recently made by Dr. C. P. Pengra, 
of Michigan, shows' that the purification of the water by freezing- 
is in no sense absokite. In experimenting with bacteria, infusoria, 
and other organisms, he found that from 9 to 1 1 per cent, re- 
mained in the ice and retained their vitahty, so that when 
thawed they rapidly multiplied, and there was no apparent 
loss of numbers. In the ordinary process of freezing the upper 
portion is the purest, but if snow or rain fall upon the ice and 
freeze this upper layer will be found much more impure than 
the lower. Rational conclusions from these experiments are, 
that ice should not be gathered from an impure source, and that 
an early harvest of the ice should be encouraged. 

In a very recent research, Prudden has shown that typhoid 
bacilli contained in water are not entirely destroyed by freezing, 
even after remaining in this condition for 103 days. 

Springs and wells supply the water for most persons not 
aggregated in large communities, as cities and towns. Even in 
the latter no inconsiderable quantity of the water used for 
drinking and domestic purposes is derived from wells. Spring- 
water usually comes from a source at a considerable depth below 
the surface; that is to say, the water has percolated through 
thick strata of soil before re-appearing at the surface. In its 
passage through the soil it has lost most of its organic matter, 
and perhaps taken up mineral and gaseous constituents in larger 
quantities. It may be so strongly impregnated with the latter 
as to vitiate it for ordinary use and to render it valuable as a 
medicine. Ordinarily, however, spring-water is clear, cool, and 
sparkling, with a refreshing taste and uniform temperature, and 
in all respects an agreeable and wholesome beverage. 

The character of w^ell-water, on the contrary, is often justly 
open to grave suspicion. Being derived from those strata of the 

1 The Dangers of Impure Ice, in The Sanitarian, May, 1882. 

^ Private communication to the autlior. The memoir of Dr, Pengra has been published 
in the Report of the Michigan State Board of Health for 1884. 



54 TEXT-BOOK OF HYGIENE. 

soil which are most likely to be contaminated by the products 
of animal and vegetable decomposition, the wholesomeness of 
the water is inversely proportional to the degree of saturation of 
the soil with the products of decay. It has been found by 
experiment that, when organic matter largely diluted with water 
is allowed to percolate through soil, it undergoes a gradual 
decomposition in the presence of certain minute organisms, 
nitrates and nitrites being formed at the expense of the ammonia 
and other organic combinations. If, however, the soil is saturated 
with organic matter in excess, and in a state of concentration, 
putrefaction takes place, and the conversion of the organic 
matter into nitrates and nitrites is retarded. Hence, the drain- 
age of diluted sewage through a stratum of porous soil, not 
already saturated with putrefying matters, has no especially bad 
significance, even if the liquid should reach a well used as a 
source of drinking-water. It is probable that by the time the 
liquid portion of the sewage reached the well it would have 
arrived at that point when it could truthfully be termed pure 
water. At the same time it must be remembered that the puri- 
fying power of the soil cannot be relied upon if the supply of 
sewage or other animal or vegetable impurity is too abundant. 

Distillation is sometimes resorted to for the purpose of pro- 
curing drinking-water, especially at sea. Vessels now generally 
carry a still for this purpose. The principal objection to dis- 
tilled water is its insipidity, due to the absence of carbon dioxide 
and mineral constituents, which give to good drinking-water its 
savor. Distilled water may be aerated by passing it in fine 
streams through holes in the bottom of a cask, elevated so as to 
allow the water to pass through a considerable stratum of air. 
Lead is sometimes taken up from the distilling apparatus, and 
may cause lead poisoning in those using the water. 

Drinking-water is sometimes procured by melting snow or 
ice. It is not probable that water derived from these sources is 
im wholesome, although there is strong popular prejudice against 
it. Ice and snow may, however, contain large amounts of 



SOURCES OF DKINKING-^ATER. 55 

impurities, as already referred to/ and be for this reason unfit 
for use. 

The following qualities are desirable in water for drinking 
and domestic purposes : — 

1. The water should be colorless, transparent, sufficiently 
aerated, of uniform temperature throughout the year, and with- 
out odor or decided taste. 

2. The mineral constituents (magnesium and lime salts) 
should not be present in greater proportion than 4 or 6 parts 
per 100,000. More than this gives to w^ater that quality known 
as " hardness." 

3. There should be but little organic matter present, and 
no living or dead animal or vegetable organisms. 

4. The water should be entirely free from ammonia and 
nitrous acid, and should contain but very small quantities of 
nitrates, chlorides, and sulphates. 

5. It should contain less than one milligramme of lead per 
litre. A larger proportion is likely to be followed by lead 
poisoning. 

IMPURITIES IN WATER. 

The transparency and the color of water are affected by 
the presence of suspended or dissolved mineral or organic mat- 
ters. If, after standing for a time, the water deposits a sedi- 
ment, this is dependent upon insoluble matters. If the sediment 
turns black when heated in a porcelain capsule over an alcohol 
or gas flame it contains organic matter. If the sediment or 
residue effervesces upon the addition of hydrochloric acid the 
presence of carbonates is indicated. Water may be colored by 
metallic salts or by vegetable matter. It may also contain large 
quantities of mineral or organic matter, or even living organ- 
isms, without perceptibly diminishing its transparency. For 
example, the ova of tape-worms may exist in water in consider- 
able numbers, and yet remain perfectly invisible except under 
the microscope. 

» See pages 52 and 53. 



56 TEXT-BOOK OF HYGIENE. 

The presence of sulphur compounds, or of various vege- 
table and animal organisms (sponges, algae, etc.^), may give to 
water an unpleasant odor and taste. In the oil regions of this 
country most of the drinking-water is contaminated with petro- 
leum, which is very disagreeable to one unaccustomed to it. It 
is not probable that the small quantities of the oil imbibed with 
the water have any deleterious influence upon the organism. 

Many works on hygiene fix a limit to the amount of solid 
matter allowable in drinking-water. The International Con- 
gress of Hygiene, at Brussels, fixed the limit at 50 parts in 
100,000. It is impossible, however, to say of any particular 
specimen of water that its content of solid matter, whether or- 
ganic or mineral, will be prejudicial to health without trial. At 
the same time it is prudent to reject all waters containing a con- 
siderable proportion of solid organic matter, as determined by 
the degree of blackening on heating the sediment or residue 
after evaporation. 

The hardness of water is due to the presence of earthy car- 
bonates, or sulphates, or both. If the hardness is due to car- 
bonates it is dissipated by heat, as in boiling the water ; the 
carbon dioxide is driven off, and the base (calcium or magnesium 
oxide) is precipitated upon the bottom and sides of the vessel. 
This is termed the "removable hardness." The hardness due 
to the presence of earthy sulphates is not removed upon heating 
the water, and is termed the "permanent hardness." The hard- 
ness depending upon both the carbonates and sulphates is called 
the "total hardness." 

The proportion of the above-mentioned earthy salts present 
in a given specimen of water is determined by what is called the 
soap test. This test depends upon the property which lime and 
magnesia salts possess of decomposing soap (oleate and stearate 
of soda). The quantity of a solution of soap of a definite com- 
position decomposed by a quantity of hard water indicates the 
amount of the salts present. In this country and England this 

* See page 52. 



IMPURITIES IN WATER. 57 

is generally expressed in degrees of Clark's scale, which are 
equivalent to grains of carbonate of lime per imperial gallon. 
Thus, if the chemist says that a certain sample of water has a 
total hardness of 16 degrees he means that the earthy salts in the 
sample decompose the same quantity of soap that w^ould be de- 
composed by 16 grains of carbonate of lime per imperial gallon. 
In Germany each degree of the scale used expresses the soap 
decomposed by 1 part of calcium oxide per 100,000. In the 
scale used in France eacli degree corresponds to 1 part of car- 
bonate of lime in 100,000. So much of the hardness of water 
as is due to carbonates can be dissipated by boiling, which drives 
off the free carbon dioxide and allows the insoluble oxides to 
be deposited as an incrustation upon the bottom and sides of 
the vessel. 

The standard soap solution for testing the hardness of 
water is made as follows : Dissolve 10 grammes of Castile soap 
in a litre of weak (35 per cent.) alcohol. One cubic centimetre 
of this solution precipitates 1 milligramme of carbonate of lime. 
The test is made as follows : To a definitely-measured quantity 
of water (say 100 cubic centimetres) in a graduated burette a 
quantity of the soap solution is added and the mixture shaken 
up; so long as there are dissolved lime or magnesium salts in 
the water the soap is decomposed and no lather is formed. Soap 
solution is now added gradually and the shaking repeated until 
there is evidence of saponification by the formation of a more or 
less permanent lather or froth. The quantity of soap solution 
used is noted, and the test is repeated. The mean of the quan- 
i *.ity of soap solution in cubic centimetres used in the two ex- 
periments will represent approximately the proportion of salts in 
grains of carbonate of lime per gallon present, or, as it is gen- 
erally expressed, in "degrees of hardness." 

The scale on the following page shows the quantity of 
soap solution required to decompose the proportion of calcium 
oxide per 100,000.' 

^ Uffelmann, Handbuch der Hjgiene, p. 94. 



68 



TEXT-BOOK OF HYGIENE. 













Table 


lY. 








1 


part CaO 


per 


100,000 water 


requires 5.4 


c.cm. 


standard soap solu 


2 


parts 




u 


u 


u 


u 


9.4 


u 


a ( 




3 


a 




u 


u 


u 


a 


13.2 


u 


a i 




4 


u 




u 


a 


i( 


a 


11.0 


u 


U i 




5 


u 




a 


u 


a 


a 


20.8 


a 


ii ( 




6 


u 




u 


u 


u 


u 


24.4 


a 


a ( 




6.5 


u 




u 


a 


a 


a 


26.2 


a 


a i 




1.0 


a 




u 


a 


u 


a 


28.0 


u 


U ( 




7.5 


u 




a 


u 


a 


a 


29.8 


u 


a i 




8.0 


u 




u 


a 


a 


u 


31.6 


u 


U I 




8.5 


u 




a 


u 


u 


u 


33.3 


u 


U ( 




9.0 


u 




u 


u 


u 


u 


35.0 


a 


U (. 




9.5 


u 




u 


a 


u 


u 


36.7 


u 


U i 




10.0 


u 




u 


u 


u 


a 


38.4 


(( 


U i 




10.5 


a 




u 


a 


u 


a 


40.1 


u 


U I 




11.0 


u 




u 


u 


a 


u 


41.8 


u 


U ( 




11.5 


u 




u 


a 


u 


a 


43.4 


u 


U i 




12.0 


u 




u 


u 


(( 


u 


45.0 


u 


U I 





If there are more than 12 parts of lime in 100,000 the 
water is diluted with an equal proportion of distilled water and 
the resultant multiplied by two. 

Mr. Wynter Blyth has proposed to take the total residue 
as representing approximately the total hardness of the water, 
but Dr. Fox points out that there may be a large excess of in- 
organic solids present in water that is quite soft and originally 
pure. 

Hard water is objectionable for domestic use, as it is waste- 
ful of soap. In cooking certain vegetables, such as peas and 
beans, the hulls are not thoroughly softened. In making infu- 
sions of tea and coifee, larger quantities of these materials are 
needed than where soft water is used. 



DISEASES DUE TO IMPURE DRINKING-WATER. 

Hard water is popularly believed to be the cause of calcu- 
lous diseases, and of goitre and cretinism, but no reliable obser- 
vations are on record showing that the belief is founded upon 






DISEASES DUE TO IMPURE DRINKING-WATER. 59 

fact. At tlie same time it is undoubtedly true that calcareous 
waters produce gastric and intestinal derangements in those 
unaccustomed to their use. 

Large amounts of suspended mineral matter are frequently 
present in river-water, and may give rise to derangements of the 
digestive organs. If there is carbonate of lime present, the 
water can be easily clarified by the addition of a small quantity 
of alum. Sulphate of lime and a bulky precipitate of hydrate 
of alumina are formed, which carry the suspended matters to 
the bottom. About 10 centigrammes of crystallized alum are 
sufficient to clarify a litre of water. This amount of alum is 
too small to affect the taste of the water perceptibly. This 
method is frequently used to clarify and render fit for use the 
w^ater of the Mississippi Kiver, which is usually very muddy. 
Dr. Parkes quotes the following striking instance of the prac- 
tical value of clarifying muddy water by means of alum.^ In 
1868 the right wing of the Ninety-second Eegiment of High- 
landers, going up the river Indus, suffered from diarrhoea from 
the use of the water, which was very muddy. The left wing 
of the same regiment used water from the same source, but pre- 
cipitated the suspended matters with alum and had no diarrhoea. 
The right wing then adopted the same plan with like success. 
Although the opinion is widespread that water containing much 
mineral matter, either in solution or in suspension, is deleterious 
to health, there is very little evidence absolutely trustworthy 
upon this point. 

CChe presence of large quantities of organic matter in water, 
whether these matters be of animal or vegetable origin, must 
always be looked upon with suspicion. The observation was 
made by Hippocrates twenty-three centuries ago, that persons 
using the water from marshes, ^.6., water containing vegetable 
matter, suffer from enlarged spleens. Many physicians, both of 
ancient and modern times, seem to have held this opinion, but 
the first positive observation in medical literature is the now 

1 Manual of Practical Hygiene, 6th ed., New York, vol i, p. 841. 



60 TEXT-BOOK OF HYGIENE. 

classical one of the ship Argo, reported by Boudin.^ In 1834 
the transport Argo, in company with two other vessels, carried 
800 soldiers from Bona, in Algiers, to Marseilles. The troops 
were all in good health when they left Algiers. All three of 
the vessels arrived in Marseilles on the same day. In two of them 
there were 680 men, not one of whom was sick. Out of the 
remaining 120 men who were on the third vessel, the Argo, 13 
died during the passage, and 98 of the 107 survivors suffered 
from paludal fevers of all forms. None of the crew of the 
Argo were sick, however. The two vessels exempt from sick- 
ness, and the crew of the Argo^ had been supplied with pure 
water, while the soldiers on the latter vessel had been furnished 
with water from a marsh. This water was said to have a dis- 
agreeable odor and taste. The testimony of a large number of 
East India physicians is also quoted by Parkes in support of 
the view that malarial fevers are often caused by impure drink- 
ing-water. The observations of Dr. Charles Smart, upon the 
production of "mountain fever" of the Western territories, 
have already been referred to. The author ventures to state it 
as his opinion, however, that the instances in which malarial 
fevers are due to impure drinking-water are very rare. 

The causation of typhoid fever and cholera by impure 
drinking-water will be presently referred to. Kecently the 
opinion has been expressed by some that yellow fever and diph- 
theria are also spread by polluted drinking-water, but no strong 
evidence has yet been adduced in its support. 

There can be very little doubt that diarrhoea and dysentery 
are frequently caused by water which has been contaminated 
with decaying organic matter. The evidence in favor of tliis 
amounts practically to demonstration. 

It must not be forgotten that the ova of certain animal 
parasites, such as distoma hematobium, filaria sanguinis hominis, 
and medinensis, anchylostoma duodenale, and possibly of round- 

^ Quoted in Parkes, op. cit., p. -18 ; Nowak, Lehrbuclx der Hygiene, p. 51 ; and in 
numerous other publications on Hygiene. 



DISEASES DUE TO IMPURE DRINKING-WATER. 61 

and tape- worms, for example, are taken into the system along 
with the drinking-water. 

Organic detritus of various kinds, sewage, decomposing 
animal and vegetable matter, refuse from manufacturing estab- 
lishments, may be a source of pollution of water and render it 
unfit for drinking or other domestic purposes. It is, however, 
not certain that water thus rendered unclean is prejudicial to 
health; in fact, Dr. Emmerich, of Munich, has recently put his 
skepticism on this point to a practical test. For two weeks he 
drank daily from half a litre to a litre of very filthy water; in 
fact, nothing less than sewage. The water was both chemically 
and physically exceedingly impure. Several of the experi- 
menter's patients partook of the same water without any ill 
efiect. He even claims that a gastric catarrh, from which he 
was sufiering when the experiment was begun, was improved 
during its course.^ 

The results of Emmerich's experiments, and of other well- 
known observations, seem almost conclusive that the products of 
animal and vegetable decomposition, taken into the body with 
the drinking-water, cannot be looked upon as certainly harmful. 
Should, however, water containing such impurities, or even 
water apparently pure, contain the germs of one of the specific 
diseases, — cholera, typhoid fever, or, perhaps, yellow, malarial, 
or scarlet fevers, or diphtheria, — it is probable that such diseases 
would be communicated to the consumer of the water. 

Many instances are on record where outbreaks of typhoid 
fever have been clearly attributable to pollution of the drinking- 
water by the germ of the disease from a previous case. 

One of the most remarkable of these outbreaks is that re- 
corded by Dr. Thorne.^ About the end of January, 1879, 
typhoid fever began suddenly in the adjoining towns of Cater- 
ham and Red Hill. Within six weeks 352 cases occurred. All 

^ Wolfflmegel : Wasserversorgung, in Pettenkofer u. Ziemssen's Handbuch der Hygiene, 
I Abth., II Hlfte, p. 97. 

=* Report of the medical officer to the Local Government Board for 1879. Quoted in JPo- 
dor : Hygienische Untersuchungen, etc., II Abth., p. 261. 



62 TEXT-BOOK OF HYGIENE. 

other sources of the disease were excluded except the drinking- 
water, to pollution of which it was traced with almost absolute 
certainty. Caterham contained 558 houses and Red Hill 1700. 
Of the former 419 and of the latter 924 drew their drinking- 
water from a common supply, having its source in a well several 
hundred feet deep. The insane asylum, with 2000 inmates, and 
the military barracks in Caterham used water from a private 
well. There was no typhoid fever among the last two commu- 
nities. During January one of the workmen engaged in some 
excavation near the public well was taken ill with diarrhoea and 
fever, — probably typhoid, — but was still able to continue his 
work. His dejections were often voided where they were cer- 
tain to become mingled with the water of the common supply. 
This man's diarrhoea began on January 5th and continued until 
the 20th of the month, during which time he remained at work. 
On the latter date he was compelled to quit work and take to 
his bed. Exactly two weeks from the beginning of the man's 
sickness, on January 19th, the first case of typhoid occurred in 
Caterham, and then rapidly increased. The first case occurred, 
therefore, just fourteen days — the incubative period of typhoid 
— after the presumed infection of the drinking-water by the de- 
jections of the sick laborer, who had come from Croydon, where 
typhoid fever was at the time prevalent. Within two weeks 
from the appearance of the first case the epidemic had reached its 
height, and then rapidly declined, disappearing almost entirely in 
a month after the outbreak. It was shown by Dr. Thorne that 
nearly all the houses in which the disease appeared were sup- 
plied with water from the source above mentioned, while other 
houses in the immediate vicinity of the infected ones remained 
free from the disease. 

In 1874 there was an outbreak of typhoid fever in the 
town of Over Darwen, in which nearly 10 per cent, of the in- 
habitants were attacked. Here the source of the disease was 
also traced to an infected water-supply. 

Dr. Buchanan has shown that an outbreak among the stu- 



DISEASES DUE TO IMPURE DRINKING-WATER. 63 

dents of the University of Cambridge was likewise attributable 
to an infected water-supply. 

In this country the reports of the Boards of Health of the 
various States teem with accounts of localized outbreaks of 
typhoid fever, referred to infected or polluted drinking-water. 
In most instances the evidence furnished by the observers is not 
conclusive. In many, however, especially of those found in the 
Massachusetts and Michigan reports, the fact of the communi- 
cation of the disease in this manner seems unquestionable. One 
of these is as follows: Out of 40 families, all using water 
from a certain well, there occurred 23 cases of typhoid fever. 
Out of 47 families, living in the same neighborhood, but using 
water from different sources, only 2 had typhoid fever.^ Dr. C. 
F. Folsom has published a very suggestive account of a house 
epidemic,^ where 9 persons in a single house, who all drank water 
from a well which was proven to be infected from a privy, were 
attacked by this disease. 

In 1885 an epidemic of typhoid fever began in Plymouth, 
a mining town of 8000 or 9000 inhabitants, situated in the 
Wyoming coal region of Pennsylvania, and on the right bank 
of the Susquehanna Piver. The epidemic began in April, and 
lasted until the ensuing September. There were 1104 persons 
attacked by the disease, of which number 114, or 10.3 per cent., 
died. The careful inspection made into the history of this 
epidemic revealed the fact that the pubhc water-supply had 
unquestionably become polluted by the faecal discharges of 
typhoid-fever patients, and the entire course of the disease, in 
this instance, is in complete accord with the view that the origin 
and spread of the epidemic were due to the pollution of the 
drinking-water with the typhoid-fever poison. 

In addition, Chantemesse and Vidal have demonstrated the 
presence of the bacillus of Eberth, which is now generally rec- 
ognized as the cause of typhoid fever, in drinking-water from 

1 Transactions Mich. Med. Society, p. 401, 1883. 

» Boston Med. and Surg. Journal, vol. cii, pp. 227, 261. 



64 TEXT-BOOK OF HYGIENE. 

a well near Paris, to which a small outbreak of t^^hoid had 
been traced. This demonstration has also been furnished by 
Prof V. C. Yaughan, in connection with an outbreak of the 
same disease in the State of Michigan. 

The numerous cases of typhoid fever which have been 
attributed to the use of infected milk may be included in this 
category. It is probable that the milk became infected either 
through polluted water used for the purpose of cleansing the 
milk-vessels or in diluting the milk. Mr. Ernest Hart has re- 
corded^ 50 epidemics of typhoid fever, 15 of scarlet fever, and 
7 of diphtheria, the cause of which he has attributed to infected 
milk. 

It is probable that typhoid fever is, in the majority of cases, 
spread through the medium of polluted drinking-water, and, in 
many of the instances on record, the relations between cause 
and effect — impure water and typhoid fever — have been so clearly 
made out as to no longer perrnit any doubt upon the question. 

As it is with typhoid fever, so also with cholera. In a later 
chapter the origin and propagation of typhoid fever and cholera 
will be discussed more fully. At the present time only the rela- 
tions of the drinking-water to the spread of these diseases can 
be considered. In the instance to be presently noted the con- 
nection between the infected water, on one hand, and the out- 
break of cholera, on the other, is so clearly shown as to be 
almost equivalent to a mathematical demonstration. The facts 
in the case were brought to light after a patient inquiry by a 
commission, whose report drawn up by Mr. John Marshall has 
made the occurrence classical. In 1854 the people of a well-to- 
do and otherwise healthy district in the eastern part of London 
suffered severely from cholera. Upon inquiry the fact was 
elicited that a child had died of cholera at No. 40 Broad Street, 
and that its excreta had been emptied into a cess-pool situated 
only three feet from the well of a public pump in that street, 
from which most of the neighboring people took their drinking- 

1 Transactions Seventh Int. Med. Congress, vol. iv, p. 391, 1881. 



DISEASES DUE TO IMPURE DRIXKIXG-TTATER. 65 

water. It was further discovered that the bricks of the cess- 
pool wall were loose and permitted its contents to drain into 
the pump-well. (It should be noted that the communication 
between the cess-pool and well was direct ; that there was im- 
mediate drainage, not percolation through the soil.) In one 
day 140 to 150 people were attacked, and it was found that 
nearly all the persons who had the malady during the first few 
days of the outbreak drank the water from the pump. ^Alien 
the pump was closed to public use by the authorities the epi- 
demic subsided. The most singular case connected with this 
outbreak was the following : In West End, Hampstead, several 
miles away from Broad Street, there occurred a fatal case of 
cholera ui a woman 59 years old. This woman formerly lived 
in Broad Street, but had not been there for many months. A 
cart, however, went daily from Broad Street to West End, 
carrying, among other things, a large bottle of water from the 
pump referred to. The old lady preferred this water to all 
others, and secured a daily supply in the manner stated. A 
niece, who was on a visit to the old lady, drank of the same 
water. She retuiiied to her home, m a high and healthy part 
of Ishngton, was hkewise attacked by cholera and died. There 
were, at this time, no other cases of cholera at West End, nor in 
the neighborhood of these last two persons attacked. 

Most of the English medical officers in India hold strongly 
to the view that cholera is spread by polluted drinldng-water, 
and the evidence in its favor is very strong. 

Quite recently (in 1885) Dr. Eobert Koch discovered the 
cholera spirillum in a water- tank in Calcutta, used as a source 
of domestic supply, and in this way furnished another link in 
the chain of evidence connecting the spirillum, the drmking- 
water, and the outbreak of the disease. 

The evidence in favor of the influence of impure drinking- 
water on the causation of other diseases than those mentioned 
is not sufficient to justify any conclusions at present. 

The source of a water-supply may be pure, yet poUution 



66 TEXT-BOOK OF HYGIENE. 

may occur before the water is used by the persons to whom 
it is distributed. Supply-pipes may become defective, and the 
water become contaminated with sewage or other deleterious 
substances. It is a current belief that no impurity can gain 
access to hydrant-pipes between the reservoir, or source of 
supply, and the point of discharge of the water. Nevertheless, 
such contamination may occur very readily. The author and 
his colleague, Dr. J. W. Chambers, of Baltimore, proved this 
conclusively a few years ago by establishing an undoubted con- 
nection between a house-epidemic of typhoid fever and a defect 
in the hydrant supplying the family with water.^ The hydrant 
was one of the class known as Clark's patent non-freezing 
hydrant. The mechanism of these hydrants is as follows : At 
the lower end of the vertical discharge-pipe is a glazed earthen- 
ware plunger, which works through a ring of rubber packing 
into a vacuum chamber. At the bottom of the vacuum chamber 
is a valve regulating the entrance of the water from the con- 
ducting-pipe. When the water is shut off this valve is kept 
closed by a spiral spring. When the crank of the hydrant is 
turned forward — that is, when the water is " turned on " — the 
plunger is forced to the bottom of the vacuum chamber, presses 
on the spring, opens the valve, and allows the water to dis- 
charge. When the crank is turned back the plunger is raised, 
releases the spiral spring, which forces the valve into its bed, and 
shuts off the water. The partial vacuum produced by the 
raising of the plunger draws the water, which is in the vertical 
discharge-pipe, into the vacuum chamber, which is so far below 
the surface as to be unaffected by frost. In course of time, 
and with use, the rubber packing gets worn and permits gradual 
leakage into the vacuum chamber of the dirty stagnant water 
by which this part of the hydrant is always surrounded. Out- 
breaks of typhoid fever having a similar origin,^ in which the 

» On Preventable Pollution of Hydrant-Water and its Relation to the Spread of Ty. 
phoid Fever. Maryland Med. Journal, vol. vii, p. 271. 

« Local Causes of Insanitatiou in Baltimore, by Jolin Morris, M.D. Report Md. State 
Board of Health, 1878. 



DISEASES DUE TO IMPURE DRINKING-TVATER. 67 

connection between cause and effect was clearly shown, have 
been reported by other physicians of the same city. 

Aside from the practical question of the causation of disease 
by polluted water, a more abstract and aesthetic idea is involved 
in consciously taking any impurity into the system. The in- 
stincts of man, as well as of most animals, revolt at it. These 
inborn instincts, which constitute the sanitary conscience, as 
Soyka says, demand purity of food and water, as they insist on 
cleanliness of the body, of clothing, and of the dwelling. 

STORAGE AND PURIFICATION OF WATER. 

Wherever a large supply of water is needed, unless drawn 
direct from a well or spring, or pumped directly from its source, 
arrangements for storage are necessary. Cisterns and large 
reservoirs are made use of for this purpose. River-water, espe- 
cially, requires a period of rest in a storage reservoir in order to 
allow deposition of the large amount of suspended matter in it. 
Prolonged storage also gives opportunity for the conversion of 
possibly deleterious organic compounds into simple and perhaps 
harmless combinations. Usually, in an elaborate system of 
water-works, a series of reservoirs is built, in which the water is 
stored successively, so that before its final distribution through 
the street-mains it has become quite clear and pure. Filtration 
on a large scale is also used in connection with storage reservoirs 
in order to secure greater purity of the water. 

In the distribution of water, care should be taken that nothing 
deleterious is taken up by the water in its passage through the 
pipes. Lead poisoning is not infrequent from drinking-water that 
has passed through a long reach of lead pipe, or which has been 
standing in a vessel lined with lead. Tanks and storage cisterns 
should therefore not be lined with lead, and the use of lead pipe 
in the supply service should be avoided as much as possible. 
Fortunately, most natural waters possess a considerable propor- 
tion of carbon dioxide, which forms with the lead an almost 
insoluble carbonate of lead. This carbonate of lead is deposited 



68 TEXT-BOOK OF HYGIENE. 

on the inside of the pipes, and protects both the pipes against 
erosive action from other constituents of the water, and also 
prevents the contamination of the water by the lead. An excess 
of carbon dioxide in the water renders this deposit soluble, and 
may cause serious poisoning. Any water which is shown by 
analysis to contain over 1 milligramme of lead per 100,000 is 
dangerous, and should be rejected. 

Owing to the possibility of defilement of the water from 
improper construction of hydrants, all outdoor hydrants should 
be discouraged as much as possible, and should be replaced by a 
simple tap-cock indoors. The pipes should also be laid deep 
enough under-ground, or otherwise protected against freezing in 
winter. 

A number of methods, all more or less efficient, have been 
introduced to purify water when it needs purification before 
being fit for use. These methods either comprise filtration or 
seek to purify the water without the aid of this process. One 
of the methods of purification without filtration consists in 
exposing the water to the air in small streams. This was pro- 
posed by Lind more than a century ago, and has since been 
frequently revived. The water is passed through a sieve, or a 
perforated tin or wooden plate, so as to cause it to fall for a 
distance through the air in finely-divided currents. By this 
process sulphuretted hydrogen, offensive organic vapors, and 
possibly dissolved organic matters are removed. This process 
has been used in Russia on a large scale. 

By boiling and agitation, carbonate of lime, sulphuretted 
hydrogen, and organic matter are removed or rendered innocuous. 
Vegetable germs are usually destroyed, although Tyndall has 
shown that some bacterial germs withstand a temperature higher 
than that of boiling water. Pathogenic germs are, however, all 
destroyed by boiling water acting upon them for ten minutes, as 
shown by Dr. G. M. Sternberg.^ 

As has already been mentioned,^ alum is one of the readiest 

» Report of Committee on Disinfectants, 1888. » See page 59. 



STORAGE AND PURIFICATION OF WATER. 69 

and most efficient means of removing suspended matters from 
water. 

Permanganate of potassium is sometimes used to purify 
water containing considerable organic matter. The perman- 
ganate rapidly oxidizes the organic matter, and is believed to 
render it harmless. There is no certainty, however, that the 
germs of specific diseases are destroyed by the action of this 
salt, in the proportion in which it could be used for the purposes 
of water purification. 

A yellow tint is given to the water by the permanganate, 
w^hich is due to finely-divided peroxide of manganese. This 
does no harm, but is unpleasant. 

"Water unfitted for use by organic matter is sometimes 
rendered usable by infusing certain vegetable astringents in it. 
Thus, it is said that in certain parts of China, where the water 
contains large quantities of organic matter, the inhabitants drink 
water only in the form of tea. The tannin of the tea-leaves 
precipitates the suspended matters and renders the water fit for 
use. Mixing the water with red wine, wliich is astringent, has 
the same effect.-^ 

Filtration is an efficient means of removing suspended 
matters. Charcoal, sand, gravel, and spongy iron are used as 
filtering material. A most economical filter is one made of fine, 
clean sand, above which layers of gravel of a gradually-increasing 
size are placed. The coarser particles of suspended matter are 
arrested before the sand, which removes most of the coloring 
and organic matters, is reached. 

Filters easily become fouled by the matters arrested in the 
interstices of the filtering material, and hence require frequent 
renewal or cleansing. A cheap and efficient filter is made by 
placing a sheet of druggists' filtering-paper in a glass funnel 
and filtering the water through it. A new and clean sheet of 
paper should be used every day. 

M. Chamberland has invented a filter w^hich is said to be 

» Champouillon, quoted in Med. and Surg. Hist, of the War, part ii med. vol., p. 613. 



70 TEXT-BOOK OF HYGIENE. 

absolutely germ-proof, but this power is not permanent, as after 
a week micro-organisms pass through the filtering material. 
The same is true of all other filters hitherto invented. 



TESTS FOR IMPURITIES IN WATER. 

Accurate and reliable quantitative analyses of water can 
only be made by chemists of experience. Every intelligent 
person should, however, know how to determine the presence or 
absence of suspected impurities. The following methods are 
simple, and easily carried out: — 

The color, transparency, and odor of water are determined 
by the unaided senses. As a standard for comparison in making 
the color test, pure, distilled water may be used. Two tubes of 
clear, white glass, 61 centimetres long, are filled with distilled 
water and with the specimen to be tested, and placed side by side 
upon a sheet of white paper. The tops of the tubes are covered 
with little squares of clear glass. The color is noted by com- 
paring the tints of the water in the two tubes. The same 
procedure may be used to determine the transparency of the 
water. 

While the color and turbidity show impurities, these are 
not necessarily prejudicial to health; on the other hand, the 
clearest and most sparkling water may contain so much poisonous 
matter as to be positively dangerous. The odor of the water is 
best ascertained by heating a small quantity in a narrow-necked 
flask to 40° to 45° C. (104° to 113° F.), and then taking a few 
strong whiffs at the flask. The odor may or may not indicate 
the presence of deleterious substances. 

The chemical examination of a water for sanitary purposes, 
short of a complete analysis, comprises the determination of the 
presence or absence of suspected impurities; in other words, it 
may be termed a qualitative analysis. In some cases an approxi- 
mate quantitative examination may also be made with little 
more trouble and skill. 



TESTS FOR IMPURITIES IN ^ATER. 71 

The examination may be divided into the following pro- 
cedures : — 

1. The determination of tlie total residue. 

2. The determination of the presence of — 

(a) Organic matter. 
(6) Chlorides. 

(c) Nitrogen compounds. 

(d) Mineral poisons. 

Determinafion of Total Solids. — Examination of the public 
water-supply of eight large cities in the United States shows 
that the total solid residue varies from 6 to 16 parts in 100,000. 
The total solids of a good drinking-water should not exceed 
25 to 30 parts per 100,000, altliough a larger quantity may be 
present without being harmful. The metliod of determining 
the total solids is to evaporate a definite quantity — say, 70 cubic 
centimetres of the water — in a previously-weighed platinum 
dish to dryness over a water-bath. The dish is then wiped dry 
and weighed again. The difference in weight between the 
empty dish and the latter with the dry residue represents the 
proportion of the latter in grains per gallon. To convert this 
figure into parts per 100,000 the number of grains per gallon 
is divided by .7. For example, if the number of grains of solid 
residue in the specimen examined is 22.4, then 

22.4 ^- .7 = 32 parts per 100,000. 

Determination of Organic Matter, — This is the most difficult 
test to apply in the sanitary examination of water. While it is 
comparatively easy to determine the presence of organic matter, 
its quantity and nature are exceedingly complex problems to 
solve. 

The presence of organic impurity in water may be detected 
by the permanganate-of-potash test, the nitrate-of-silver test, 
and the incineration test. Neither of these processes is compe- 
tent to differentiate noxious from inoffensive organic matter. 
The permanganate test, modified by Dr. DeChaumont, is the 



72 TEXT-BOOK OF HYGIENE. 

one usually adopted. The process is as follows: To 250 cubic 
centimetres of the water to be examined add 5 cubic centimetres 
of dilute sulphuric acid (10 per cent.) in a clear, white glass 
flask. Then add permanganate of potassium solution (395 
milligrammes to 1 litre of distilled water) until the water has 
taken a pink tinge. Heat the water to 140° F. (60° C), adding 
permanganate solution if the color disappears. When the tem- 
perature above mentioned is reached remove the flask from the 
burner, and add permanganate drop by drop until a faint pink 
color is obtained, which remains permanent for. ten minutes. 
Read ofl" the number of cubic centimetres of the permanganate 
solution used as required for total oxidizable matter. As the 
solution of permanganate yields in presence of an acid 0.1 of a 
milligramme of oxygen for each cubic centimetre, it is evident that 
the number of cubic centimetres of solution decomposed has 
furnished an equal number of tenths of a milligramme of oxygen 
which has entered into other combinations. 

But, inasmuch as all the oxidizable matter in the water 
may not be organic, the inorganic oxidizable matter (nitrous 
acid) must be separated. This is done by first boiling the water 
with sulphuric acid, as above (250 cubic centimetres + 5 cubic 
centimetres), for twenty minutes, to remove the nitrous acid. 
Then allow the acidulated water to cool down to 60 degrees 
and add the permanganate until a pink color is obtained for ten 
minutes. The amount of permanganate solution used gives the 
number of milligrammes of oxygen required for oxidizable 
organic matter. 

Determination of Glilorides. — Chlorine, or its compounds, 
when present in drinking-water, represent generally sewage 
pollution. It is true that chlorine may be in excess in water, 
and the latter, nevertheless, be entirely free from sewage or 
urine, but this occurs only where there is a natural deposit of 
chlorine compounds in the soil from which the supply is drawn. 
If communication with the sea or salt-deposits is excluded, the 
chlorine may be assumed to be due to the inflow of sewage. 



I 



TESTS FOR IMPURITIES IX T7ATER. 73 

Especially is this the case if the test for organic matter has given 
positive resnlts. The proportion of chlorine may be estimated 
thus: Place 70 cubic centimetres of the water into an evapo- 
rating dish, and add a small fragment of neutral chromate of 
potash. Then, by means of a pipette graduated to tenths of a 
cubic centimetre, standard solution of nitrate of silver^ should 
be allowed to drop mto the water until the red color produced 
remains permanent. The number of cubic centimetres of the 
silver solution required to produce the permanent red tint is 
equivalent to the number of grains of chlorine per gallon, which, 
if divided by .7, gives the parts per 100,000. 

Another method of determining the presence of chlorine or 
chlorides is as follows: Acidulate about 16 cubic centimetres of 
the water to be tested with pure nitric acid, and add a few drops 
of a solution of nitrate of silver (1.5 grammes to 32 cubic cen- 
timetres of distilled water). A white precipitate, gradually 
changing to gray, is produced if chlorides are present. The 
degree of cloudiness produced wdll indicate approximately the 
amount of chlorides : '• 1 .5 parts of chlorine per 100,000 give 
a haze; 5.7 parts per 100,000 give a marked turbidity; 14 parts 
per 100,000, considerable precipitate." If the chlorine is found 
by this test to exceed 1.5 parts per 100,000, the source of the 
contamination should be searched for. If drainage from a cess- 
pool is suspected, a quantity of salt water may be thrown into 
it, and the water again tested after an interval of four hours to 
see whether the chlorine has increased. 

Determination of Nitrites and Nitrates. — The presence of 
these nitrogen compounds in drinking-water should excite sus- 
picion of sewage contamination. They are the resultants of 
oxidation of nitrogenous organic matter, and, although water 
containing them is not necessarily dangerous, their presence 
should render a thorough examination of the source of supply 
imperative. 

^ Stan dm- d Solution of Nitrate of Silver. — Dissolve 4.79 ^ammes of crj-stallized nitrate 
of silver in 1 litre of distilled water. One cubic centimetre of this solution precipitates 1 milli- 
gramme of chlorine. 



74 TEXT-BOOK OF HYGIENE. 

The readiest method of detecting nitrates and nitrites in 
water is by the pyrogallol test. This may be performed as fol- 
lows : Put 2 cubic centimetres of pure sulphuric acid in a small 
test-tube and add 1 cubic centimetre of the water to be tested. 
To this mixture is added 1 drop of a solution of pyrogallol 
{6d centigrammes to 30 cubic centimetres) in distilled water, 
acidulated with 2 drops of sulphuric acid. The water becomes 
colored a dark amethyst or wine brown if the salts are present. 
The depth of color indicates approximately the amount of the 
impurity. 

The following test for nitric acid or nitrates may also be used : 
A small quantity of the water is evaporated to dryness, and a 
few drops of a solution of carbolic acid in 4 parts of con- 
centrated sulphuric acid and 2 parts of distilled water added 
to the residue. If nitric acid is present, a brownish-red color 
results, which turns green and then yellow upon the addition of 
ammonia. 

Nitrous acid or nitrites will give a reaction with iodide of 
potassium and starch ; 350 to 600 cubic centimetres of water 
in a flask are acidulated with a few drops of dilute sulphuric 
acid, and a little solution of iodide of potassium added. About 
2 grammes of freshly-prepared starch are added and the mixture 
shaken. If nitrous acid is present, the iodide is decomposed, 
setting free the iodine, which combines with the starch, causing 
a blue color. The test is a very delicate one. 

Ammonia. — The presence of this is determined by Nessler's 
reagent,^ as follows : 100 cubic centimetres of the water to be 
examined is treated with 0.5 cubic centimetre of caustic soda 
solution and 1 cubic centimetre of carbonate of soda solution 
to precipitate the earthy salts. After the precipitate has sub- 
sided, 1 cubic centimetre of Nessler's reagent is added. If 
ammonia is present the water takes a yellowish tint. 

» JVessler's Heagent.— Dissolve by heating and stirring 35 grnmnies of potassium iodide 
and 13 grammes of mercuric chloride in 800 cubic centimetres of distilled water. Add gradually a 
cold aqueous saturated solution of mercuric chloride until the red color pro;lured just begins 
to be permanent ; 160 grammes of solid caustic potash are then added to the mixture which is to 
be diluted with distilled water until it exactly measures one litre. 



i 



TESTS FOR IMPURITIES IN ^ATER. 



75 



Determination of Mineral Poisons, — Of these the most 
important are lead, copper, zinc, and arsenic. The presence of 
any of these in even the smallest quantity is dangerous, and, if 
constant, the water so contaminated should not be used for 
drinking purposes. 

In order to detect lead 250 cubic centimetres of the water 
is first treated with hydrochloric acid, and then sulphuretted 
hydrogen (in aqueous solution) is added. If a brownish or 
black precipitate results, either lead or copper may be present. 

On filtering the water, dissolving the residue in hot, diluted 
nitric acid, and adding a solution of potassium bichromate, a 
yellow precipitate, soluble in caustic potash, is thrown down if 
lead is present. If the precipitate produced by sulphuretted 
hydrogen is dissolved, as above, and ammonia added, a blue 
color is produced in the presence of copper. To detect zinc the 
sulphuretted hydrogen precipitate is treated with caustic soda, 
again filtered, and sulphuretted hydrogen added to the filtering 
liquid. A white precipitate indicates the presence of zinc. 

Arsenic is detected by Marsh's test. Mr. A. J. Cooper has 
prepared the following table showing the accuracy of certain 
tests employed for the determination of poisonous metals in 



drinking-water : — 












Table Y. 




Meta 


1. Reagent. 


Depth of Liquid, Z% 
Inches. 


Depth of Liquid, lA}^ 

Inches (cylinder inclosed 

in opaque tube). 






1 part of metal detected in 


1 part of metal detected in 


Copper 


. . K^CjeFe 


4,000,000 of wa 


ter. 


11,750,000 of water. 


Copper 


. . NH.HO 


1,000.000 " 




1,950,000 " 


Copper 


. . H,S 


4,150,000 " 




15,660,000 " 


Zinc . 


. . NH4HS 


2,500,000 " 






Arsenic 


. . H2S 


3,600,000 " 




7.520,000 " " 


Lead . 


. . KaCrO^ 


4,000,000 " 




5,875,000 " 


Lead . 


H,S 


100,000,000 '' 


196,000,000 " 



In making the tests a tall glass is used, and the formation 
of the precipitate observed by looking down pei-pendicularly 
through the column of liquid of 3f inches (95 millimetres) and 
14i inches (368 millimetres) respectively. 



76 TEXT-BOOK OF HYGIENE. 



SIGNIFICATION OF THE VARIOUS IMPURITIES INDICATED BY THE 
FOREGOING TESTS. 

The following summary gives, briefly, the inferences tha 
may be drawn from the result of the foregoing tests^ : — 

"If chlorine be present inconsiderable quantity it eithei 
comes from strata containing chloride of sodium or calcium 
from impregnation of sea-water, or from admixture of liquic 
excreta of men and animals. In the first case the water is 
often alkaline from sodium carbonate ; there is an absence, o] 
nearly so, of oxidized organic matters, as indicated by nitric an( 
nitrous acids and ammonia, and of organic matter; there is 
often much sulphuric acid. If it be from calcium chloride there 
is a large precipitate with ammonium oxalate after boiling. If 
the chlorine be from impregnation with sea-water, it is often in 
very large quantity ; there is much magnesia, and little evidence 
of oxidized products from organic matters. If from sewage the 
chlorine is marked, and there is coincident evidence of nitric and 
nitrous acids and ammonia, and if the contamination be recent 
of oxidizable organic matters. 

"Ammonia is almost always present in very small quan- 
tity, but if it be in large enough amount to be detected without 
distillation it is suspicious. If nitrates, etc., be also present, it 
is likely to be from animal substances, excreta, etc. Nitrates 
and nitrites indicate previously-existing organic matters, prob- 
ably animal, but nitrates may also arise from vegetable matter, 
although this is probably less usual. If nitrites largely exist it 
is generally supposed that the contamination is recent ; the co- 
incidence of easily-oxidized organic matters, of ammonia, and 
of chlorine in some quantity, would be in favor of an animal 
origin. If a water gives the test of nitric acid, but not of 
nitrous acid, and very little ammonia, either potassium, sodium, 
or calcium nitrate is present, derived from soil impregnated 
with animal substances at some anterior date. If nitrites are 

1 Parkes' Hygiene, vol. i, p. 79. 



J 



SIGNIFICATION OF VARIOUS IMPURITIES. 77 

present at first, and after a few days disappear, this arises from 
continued oxidation into nitrates ; if nitrates disappear it seems 
probable tliis is caused by the action of bacteria or other low 
forms of life. Sometimes in such a case nitrites may be formed 
from the nitrates. Lime in large quantity indicates calcium car- 
bonate if boiling removes the lime, sulphate or chloride or ni- 
trate if boiling has little effect. Testing for calcium carbonate 
is important in connection with purification with alum. Sul- 
phuric acid in large quantity, with little lime, indicate sulphate 
of sodium, and usually much chloride and carbonate of sodium 
are also present, and on evaporation the water is alkaline. 
Large evidence of nitric acid, with little evidence of organic 
matter, indicates old contamination ; if the organic matter be 
large, and especially if there be nitrous acid as well as nitric 
present, the impregnation is recent." 

THE BIOLOGICAL OR BACTERIOLOGICAL EXAMINATION OF DRINKING- 
WATER. 

Since the development of the methods of cultivation of 
micro-organisms by Koch and his pupils, and their employment 
for the study of water pollution by Meade Bolton, Wolff liiigel 
and Riedel, Percy Frankland, Prudden, and others, and the un- 
satisfactory results of chemical analysis, some sanitarians have 
expressed the conviction that the biological method is the only 
exact one for determining water pollution from a sanitary point 
of view. While this may be conceded, it is also true that very 
few health officers are competent to give an expert opinion upon 
the nature of the organisms which may be found in the water 
examined. It requires but little technical skill to make cultiva- 
tions of bacteria from samples of water, but only an expert 
bacteriologist may safely pronounce upon the nature of the 
organisms constituting the various colonies which develop upon 
the nutritive gelatin. Just as the mere presence of organic 
matter as determined by the chemist is not indicative of a dan- 
gerous quality in the water unless the kind of organic matter 



78 



TEXT-BOOK OF HYGIENE. 



and its derivation be also specified, so likewise the presence of 
bacteria alone is of small significance ; the danger consists not 
in bacteria, but in certain kinds of bacteria. The differential 
diagnosis is possible only to the trained bacteriologist. 

While, as stated, a positive decision as to the sanitary value 
of a water may often be impossible, there are certain chemical 
and microscopical features which stamp a water as good or bad. 
Dr. DeChaumont gives an approximate valuation which may 
often serve as a useful guide. ^ 

He classifies water under the four heads of Pure and 
Wholesome Water, Usable Water, Suspicious Water, and Im- 
pure Water. The characters of these waters are arranged in a 
series of tables, the essential details of which are given in 
Table VI, 

Table YI. 



I 





Pure 


Usable 


Suspicious 


Impure 




Water. 


Water. 


Water. 


Water. 


CHEMICAIi 










Constituents. 












I. 


II. 


III. 


IV. 




Parts in 100,000. 


Parts in 100,000. 


Parts in 100,000. 


Parts in 100,000. 


Chlorine in solution . 


Under 1.4000 


Under 4.2857 


4-7 


Above 7.1428 


Solids " total . 


" 7.1428 


" 42.8571 


43-71 


*' 71.4285 


" " volatile 


" 1.4000 


" 4.2857 


4-7 


" 7.1428 


Ammonia, free or sa- 










line 


•' 0.0020 


" 0.0050 


0.0050-0.0100 


" 0.0100 


Ammonia, albuminoid 


" 0.0050 


" 0.0100 


0.0100-0.0125 


" 0.0125 


Nitric acid in nitrates 


" 0.0323 


" 0.5000 


0.5-1.0 


" 1 0000 


" " nitrites 


Nil. 


Nil. 


0.0500 


" 0.0500 


Nitrogen in nitrates . 


" 0.0140 


" 0.1129 


0.1243-0.2373 


*' 2415 


Total nitrogen . . . 


'' 0.0230 


- 0.1252 


0.1255-0.2465 


** 0.2(J01 


Oxygen absorbed by 










permanganate and 










acid within half an 










hour at 140° F. . . 


" 0.0250 


" 0.1000 


0.1000-0.1500 


" 0.1500 


Total hardness . . . 


" 8.5 


" 17.3 


Above 17.0 


" 28.5 


Permanent hardness . 


" 3.0 


" 5.7 


" 5.7 


- 8.7 


Phosphoric acid in 










phosphates . . . 


Traces. 


Traces. 


Heavy traces. 


Heavy traces. 


Sul ^huric acid in sul- 










p lates 


" 


Under 3.000 


Above 3.000 


Above 4.2857 


Heavy metals . . . 


Nil. 


Traces. 


Traces. 


( Any except 
( iron. 
Present. 


Hydrogen sulphide . 


" 


Nil. 


Nil. 


Alkaline sulphides . 


" 


<< 


" 


" 



» Parkes' Hygiene, vol. i, pp. 103-106. 



EXAMINATION OF DRINKING-TTATER. 



79 



Physical Characters. 

No. I. Colorless, or bluish tint ; trans- 
parent, sparkling, and well aerated ; no 
sediment visible to naked eye ; no smell ; 
taste palatable. 

No. II. Colorless, orsliglitly greenish 
tint ; transparent, sparkling, and well 
aerated ; no suspended matter, or else 
easily separated by coarse filtration or 
subsidence ; no smell ; taste palatable. 

No. III. Yellow, or strong, green 
color ; turbid ; suspended matter con- 
siderable ; no smell, but any marked 
taste. 

No. IV. Color, yellow or brown ; tur- 
bid, and not easily purified by coarse 
filtration ; large amount of suspended 
matter ; any marked smell or taste. 



Microscopical Characters. 
No. I. Mineral matter ; vegetable 
forms with endochrome ; large animal 
forms ; no organic debris. 

No. II. Same as No. I. 



No. III. Vegetable and animal forms 
more or less pale and colorless ; organic 
debris; fibres of clothing, or other evi- 
dences of house-refuse. 

No. IV. Bacteria of any kind ; fungi ; 
numerous vegetable and animal forms 
of low types ; epithelia, or other animal 
structures ; evidences of sewage ; ova 
of parasites, etc. 



[The following works are recommended to those desirmg 
fuller information upon the subjects embraced in the foregoing 
chapter : — 

Water Supply, by Wm. Ripley Nichols, N. Y., 1884.— A Guide to 
the Microscopic Examination of Drinking-Water, by J. D. MacDonald, 
R.N.F.R.S. — Sanitar}' Examinations of V^ater, Air, and Food, by Fox. — 
Report of the Committee on Water Pollution, Public Health, vol. xiv. 
Zeitschr. f. Hygiene, vol. i, by Bolton. — Prudden in N. Y. Medical 
Record, 1887. — Arb. aus d. Reichsgesimdheitsamte, I, Wolffhugel and 
Riedel.] 



CHAPTER III. 

Food. 

Tn order to preserve health and vigor it is necessary for 
animal beings to consume at intervals a sufficient quantity of 
substances known as foods. Alimentary substances, or foods, 
may, therefore, be briefly defined as materials which, taken into 
the body and assimilated, sustain the processes of life, promote 
growth, or prevent destruction of the organized constituents of 
the body. 

QUANTITY AND CHARACTER OF FOOD NECESSARY. 

It has long been known, as the result of the empirical 
observation of feeding large bodies of people, that the various 
proximate principles composing the tissues must be combined in 
certain definite proportions in the food in order to preserve the 
normal degree of health and vigor of the body. Within a 
comparatively recent period physiologists have made experi- 
ments upon animals and human beings which have led to the 
same conclusions, and have enabled these proportions to be 
fixed with more or less exactness. 

Considering man as an omnivorous animal, it may be laid 
down as an invariable rule that the foUoAving four alimentary 
principles are necessary to his existence.^ Neither of these 
principles can be dispensed with for a prolonged period without 
illness or death resulting. 

1. Water. — This must be supplied in sufficient quantity 
to permit the interchange of tissue to be carried on in the body. 

2. Salts. — Inorganic compounds of various kinds are 

» Physiologie, Landois, 2te Aufl., p. 448. 

(81) 



82 TEXT-BOOK OF HYGIENE. 

necessary to the preservation and proper construction of the 
tissues. They are all found in sufficient quantities in the 
various alimentary substances consumed by man and the lower 
animals. A deficiency of inorganic constituents in the food is 
followed by disease. 

3. Proteids. — Organic nitrogenous material, either animal 
or vegetable, is a necessary constituent of the food of man. 
Continued existence is impossible without a sufficient supply of 
nitrogenous substances. 

4. Fats or CarhoJii/drates.— The organic non-nitrogenous 
or carbonaceous principles of food are also necessary to the 
continuance of health. They are supplied either by fats or by 
carbohydrates (sugar, starch, etc.), which may, within certain 
limits, be used as substitutes for each other. Voit has shown 
that 1 7 parts by weight, of starch, is equivalent as carbonaceous 
or oxidizable food to 10 parts of fat. 

The physiology of nutrition has been very carefully studied 
by a large number of experimental physiologists, who have 
arrived at conclusions differing widely from those generally 
accepted twenty-five years ago. The division of foods into 
plastic and respiratory foods, or, in a general way, into proteids 
or muscle-builders, and fats and carbohydrates, or oxidizing 
foods, is now no longer recognized in science. It has been 
established that proteid tissues are not alone the result of proteid 
food, and that the accumulation of fat in the body is not altogether 
due to the excessive consumption of fats and carbohydrates. It 
has been further shown, contrary to the general belief, that the 
nitrogenous or proteid tissues are not used up during hard labor 
any faster than when at perfect rest, but that, on the contrary, 
increased muscular exertion is attended by increased consump- 
tion of stored-up fat. 

These facts have led to a modification of the standard 
dietaries formerly employed. At present the standards of the 
quantity of food principles required to maintain equality between 
bodily income and expenditure are those calculated by Professor 



QUANTITY AND CHARACTER OF FOOD NECESSARY. 



83 



Yoit, after many experiments upon human beings and the lower 
animals. These standards are as follow : — 



Table TII. 

adult male of average weight. 



At Rest. 



iSIoderate Labor. 



Severe Labor. 



Proteids . . 
Fats .... 
Carbohydrates 



110 grammes 

50 " 
450 " 



118 grammes 

50 " 
500 " 



145 grammes 
100 

500 •' 



As the average weight of women is less than that of men, 
a reduction of from 15 to 20 per cent, in the various food prin- 
ciples may be made for the female ration. 

The relative proportion of nitrogenous to non-nitrogenous 
principles in this ration is about 1 to 5. In the older diet 
standards, e.g.^ Moleschott's, the proportion of nitrogenous to 
non-nitrogenous principles is much larger, being, for a man at 
moderate labor, proteids, 130 grammes; fats, 84 grammes; and 
carbohydrates, 404: grammes, or about 1 to 3.75. 

While from ignorance, or motives of economy, many men 
sustain life and preserve health at hard labor on rations varying 
considerably from the standard above given, it is probable that, 
all things being considered, the most perfect physiological ration 
would also be the most economical. Thus, Professor Yaughan 
proposes a daily ration consisting of bread, cod-fish, lard, potatoes, 
bacon, beans, milk, sugar, and tea in such proportions as to fur- 
nish 123 grammes proteids, 70 grammes fats, and 550 grammes 
carbo-hydrates. The total cost or money value of this ration at 
present prices is about thirteen cents. In actual food value it 
is not inferior to the daily fare of the liahitue of Delmonico's. 

The above standard diet-tables give the relative proportions 
of food principles in terms of their proximate chemical composi- 
tion. In practice it is very necessary to choose such food ma- 
terials as will represent approximately the proximate prmciples 



84 



TEXT-BOOK OF HYGIENE. 



required. The following tables give the approximate value in 
proteids, fats, carbohydrates, and salts of a number of articles 
used as food: — 

Table YIII. 



ANIMAL FOODS. 



Articles. 



Moderately fat beef . . 
Ox-heart (fat animal) . 

Fat veal 

Moderately fat mutton 

Lean pork 

Salt liam 

Hare 

Venison 

Horse-flesh 

Liver-sausage 

Beef-extract 

Chicken (lean) . . . . 

Pi2;eon 

Wild duck 

Haddock 

Herring (freshi) . . . . 

Roach 

Mackerel 

Conger-eel 

Salmon 

Carp 

Pike 

Sole 

Oyster 

Caviar 

Beef-liver 

Calf's brains 

Sweet-bread 

Fat of pork (salt) . . . 

Hen's egg 

White of egg 



CoTv's milk 
Human milk . . 

Cream 

Rich cheese . . 
Lean cheese . . 

Butter 

Whey 

Kumys 

Condensed milk. 



V S3 

ft 



72.25 

70.08 
72.31 
75.99 
72.57 
62.58 
74.16 
75 76 
74.27 
48.70 
21.70 
76.22 
75.10 
70.82 
80.92 
80.71 
75.49 
68.27 
79.91 
76.38 
76.97 
77.45 
86 14 
89.69 
45.05 
72.02 
74.14 
70.00 
9.15 
73.67 
85.75 
50.82 
87.41 
87.09 
66.41 
35.75 
48.02 
14.14 
93.31 
87.88 
30.34 






21.39 
21.51 
18.88 
18.11 
19.91 
22.32 
23.34 
19.77 
21.71 
15.93 

19.72 
22.14 
22.65 
17.09 
10.11 
22.23 
23.42 
13.57 
13.10 
20.61 
20.11 
11.94 

4.95 

31.90 

19.59 

(8 albumen) 

27.00 

9.72 
12.55 
1267 
16.24 

3.31 

2.48 

3.70 
27.16 
32.65 

0.86 

0.82 

2.83 
16.07 



^u 



5.19 
7.47 
7.41 
5.77 
6.81 
8.68 
1.13 
1.92 
2.55 

26.33 

60 79 
1.42 
1.00 
3.11 
0.35 
7.11 
0.47 
6.76 
5.02 
4.57 
1.09 
0.69 
0.25 
0.37 

14.14 
5.60 

13.14 
0.35 

75.75 

12.11 
0.25 

31.75 
3.66 
3 90 

25.72 

30.43 
8.41 

83.11 
0.24 
94 

12.10 






■5§ 



0.16 
0.07 



0.19 
1.42 
0.46 
6.38 

1.27 
0.76 
2.33 



0.39 
4.67 

*0.'92 
0.45 
2.62 

1.10 

11.65 

'o!55 

0.13 
4.92 
6.04 
3.54 
2.53 
6.80 
0.70 
4.98 
7.08 
38.882 



1.17 
0.78 
1.33 
1.33 
1.10 
6.42 
1.18 
1.13 
1.01 
2.66 
17.51 
1.37 
1.00 
1.09 
1.64 
2.07 
1.71 
1.85 
1.11 
1.28 
1.33 
0.83 
1.22 
2^37 
8.91 
1.69 
1 
1. 
5.38 
1.12 
0.59 
1.09 
0.70 
0.49 
0.63 
4.13 
4.12 
1.19 
0.65 
1.07 
2.61 



» Containing 16 per cent, nitrogen. 



2 Containing 22.26 per cent, cane-sugar. 



QUANTITY AND CHARACTER OF FOOD NECESSARY. 



85 





Table IX. 












VEGETABLE FOODS. 








^1 


,2^ 


i 

2 


if 


in 

5S:I 
O 


El. a 
eg 




m 

Ph 


13.56 


12.42 


1.70 


1.44 


66.45 


2.66 


1.77 


1 : 5.7 


12.09 


11.02 


2.77 




66.44 


5.47 


2.21 


1 


6.5 


15.26 


11.43 


1.71 


0.96 


66.86 


2.01 


1.77 




6.2 


13.78 


11.16 


2.12 




65.51 


4.80 


2 63 




6.2 


12.92 


11.73 


6.04 


2.22 1 53.21 


10.83 


8.05 




5.6 


13.88 


10.05 


4.76 


4.59 


62.19 


2.84 


1.69 




7.5 


13.23 


7.81 


0.69 


. . . 


76.40 


0.78 


1.09 




9.9 


11.26 


11.29 


3.56 


1.18 


66.15 


4.25 


2.31 




6.5 


11.36 


10.58 


2.79 


• . . 


55.84 


16.52 


2.91 




5.7 


14.84 


23.66 


1.63 


. . . 


49.25 


7.47 


8.15 




2.3 


14.31 


22.63 


1.72 




53.25 


5.45 


2.65 




2.5 


12.51 


24.81 


1.85 




54.78 


3.58 


2.47 




2.3 


14.86 


8.91 


1.11 


2.32 


71.86 


0.33 


0.61 




8.5 


14.42 


10.97 


1.95 


3.88 65.86 


1.62 


1.48 




6.7 


15.06 


11.75 


1.71 


3.10 67.80 


0.11 


0.47 




6.3 


14.27 


9 28 


1.89 


1.06 71.40 


0.89 


1.21 




8.2 


10.46 


15.50 


6.11 


2.25 61.42 


2.24 


2.02 




4.8 


14.00 


11.10 


8.10 


. . . 65.10 




1.70 




6.7 


14.84 


1.46 






83.31 




0.39 




57.1 


13.07 


9.02 


0.28 


. 


76.79 




0.84 




S.Q 


38.51 


6.82 


0.77 


2.37 


49.97 


0.88 


1.18 




7.9 


44 02 


6.02 


0.48 


2.54 i 45.33 


0.30 


1.31 




8.1 


7.45 


7.18 


9.28 


17.02 


58.08 


0.16 


0.83 




12.7 


75.77 


1.79 


0.16 




20.56 


0.75 


0.57 




11.6 


87.88 


1.07 


0.11 


6.55 


2.43 


1.02 


0.94 




8.6 


83.91 


2.08 


0.11 


9.31 


2.41 


1.14 


1.04 




5.7 


90 51 


1.40 




4.68 


2.14 




1.27 




5.8 


87.05 


1.04 


0.21 


6.74 


2.66 


1.40 


0.90 




9.4 


88.32 


1.04 


0.21 


1.60 


7.17 


0.95 


0.71 




8.8 


91.24 


0.96 


0.16 


4.08 


1.90 


0.91 


0.75 




6.5 


86.92 


2.92 


0.11 


1.53 


6.90 


1.55 


1.07 




4.5 


76.72 


2.73 


0.35 




15.89 


2.78 


1.53 




6.0 


85.01 


2.95 


0.22 


0.40 


8.45 


1.76 


1.21 




3.1 


70 18 


2.68 


0.10 


5.78 19.91 


0.81 


0.54 




9.6 


87.62 


2.83 


0.29 


0.44 i 6.09 


1.49 


1.24 




2.5 


64.66 


6.76 


0.06 


. . . ! 26.31 


0.77 


1.44 




3.9 


95.60 


1.02 


0.09 


0.95 1.33 


0.62 


0.39 




2.4 


95.21 


1.06 


0.61 


0.27 1.15 


1.07 


0.63 




2.4 


90.01 


0.71 


0.05 


1.36 5.87 


1.36 


0.64 




10.2 


92.87 


1.25 


0.33 


2.53 1 1.55 


0.84 


0.63 




3.6 


93.32 


1.98 


0.28 


0.40 2.34 


1.14 


0.54 




1.6 


80.49 


5.75 


0.50 




10.86 


1.60 


0.80 




2.0 


86.10 


4.67 


0.30 




6.60 


1.69 


0.64 




1.5 


90.39 


2.53 


0.38 


1.27 


3 74 


0.87 


0.82 


1 


2.2 


80.03 


3.99 


90 


1.21 


10.42 


1.88 


1.57 




8.3 


87.09 


3.31 


0.71 


1.29 


4.78 


1.28 


1.64 




2.2 


85.63 


4.83 


0.46 




6.22 


1.57 


1.29 




1.5 


90.26 


3.15 


0.54 


0.08 


8 26 


0.77 


1.94 




1.3 


94.33 


1.41 


0.31 




2.19 


0.73 


1.03 


^ 


1.9 



AliTICLES. 



Wheat 

Spelt 

Rye 

Barley 

Oats 

Indian corn .... 

Hulled rice 

Millet 

Buckwheat 

Beans 

Peas . 

Lentils ' 

Wheat-flour .... 

Rye-flour 

Barley-flour .... 
Buckwheat-flour . . 

Oatmeal 

Cornmeal 

Starch 

Macaroni 

Fine wheat-bread. . 
Fresh rye-bread . . 

English biscuit i 

Potatoes 

Beet (red) 

Sugar-beet 

Mangold root. . . . 

Carrot (large) . . . 

" (small) . . . 

Turnip 

Radish 

Horseradish .... 

Kohl-rabi 

Onion 

Leek 

Garlic 

Cucumber 

Melon 

Pumpkin 

Tomato 

Asparagus 

Green peas 

Snap beans 

Cauliflower 

"Winter cabbage. . . 
Savoy cabbage . . . 
Red cabbage .... 

Spinach 

Lettuce 



86 



TEXT-BOOK OF HYGIENE. 



Table IX {continued). 

VEGETABLE FOODS. 



Articles. 





. 






^U 


2^ 




u->^ 


-rt^" 


+i 


. .ii 


G^ © 


B^ 


^ 


^% 




f^§5 


a- 


t ■- 


^% 


r- S 


(A u 


4^ « 


c5 o 


6po 


O o) o 




m Q 




ll 


'^l 


^1 


33 i- 














o 


'^^ 




91.11 


2.57 


0.13 


1.05 


3.71 


0.67 


0.76 


17.54 


23.84 


1.21 


9.59 


34.56 


6.21 


7.05 


72.80 


8.91 


0.62 




7.54 


7 92 


2.21 


83.58 


0.39 




7.73 


5 17 


1.98 


0.31 


83 03 


0.36 


. . . 


8 26 


3.54 


4 30 


0.31 


84.86 


0.40 


. . . 


356 


4.68 


4 34 


0.66 


80.03 


0.65 




4 48 


7.17 


6.06 


69 


81.23 


49 


. . . 


4 69 


6.35 


5.27 


0.82 


80.26 


62 


. . . 


10.24 


1 17 


6.07 


0.73 


78.17 


0.59 




14.36 


1.96 


3.60 


0.53 


87.66 


1.07 


0.45 


6.28 


0.48 


2.32 


081 


86.21 


0.53 




3.95 


1.54 


5.90 


49 


86.41 


0.51 


. . . 


4.44 


1.76 


5 21 


0.48 


84.71 


0.36 


. . . 


9.19 


2 31 


0.91 


0.66 


78.36 


0.78 




5.02 


0.87 


12 29 


1.02 


85.74 


0.47 


. . . 


7.03 


1.40 


3 52 


0.42 


84.77 


0.51 


. . . 


6.38 


90 


4.57 


0.72 


32.42 


1.06 




41 61 


14.68 


5.59 


1.96 


2941 


207 


0.35 


2913 


29.67 


6 86 


1.67 


29.83 


2 55 


0.53 


42.65 


18.85 


1.43 


1.39 


49.88 


2.07 


30 


31.22 


14.29 


0.612 


1.63 


32.02 


2.42 


0.59 


54 56 


7.48 


1.72 


1.21 


32.21 


5.06 




45.28 






2.96 


5.39 


24.18 


53 68 


. . . 


7.23 


6.56 


2.96 


4.68 


16 37 


62.86 


• . . 


7.89 


6.17 


2.03 


3.77 


15.62 


66.47 




9.03 


3.28 


1.83 


51.48 


5 48 


1.37 




38.34 


1.61 


1.72 


6.50 


28.20 


46.40 


. . . 


15.70 




3.20 



o S s j^ 
0, 



Mushrooms (fresh) 
" (dried) 

Truffle 

Apples 1 

Pears 

Plums 

Peaches 

Apricots 

Cherries 

Grapes 

Strawberries . . . 

Raspberries . . . . 

Blackberries . . . , 

Mulberries . . . . . 

Whortleberries. . , 

Gooseberries . . . , 

Currants , 

Dried apples . . . , 
" pears . . . , 
" prunes. . . . 
" cherries . . . 
" raisins. . . , 
" figs 

Sweet almonds . . . 

Walnut 

Hazel-nut 

Chestnuts (fresh) . 

Peanut , 



19 

19 

1.0 

35.2 

33.3 

24 3 

19.3 

24 9 

19.9 

29 

78 

13.0 

14.5 

37.1 

9.7 

21.0 

18.5 

55.6 

29.1 

25.5 

22 2 

26 

8.9 

4.3 

73 

8.0 

7.5 

2.3 



In addition to maintaining a proper proportion between the 
various alimentary principles, it is necessary to vary the articles 
of food themselves, otherwise they are liable to prove nauseating. 
The necessity of variety in the food, in order to preserve the 
appetite, is familiar to every one. 

By keeping the proportions of the above table in view it 
will be seen at once that if a man wished to live on beef alone 
he would be obliged to eat about 2 kilogrammes per day in 
order to get a sufficient amount of non-nitrogenous food. Of 



» These green fruits all contain in addition from .2 to 2.1 per cent, of free acid. 
' Without stones. 



QUANTITY AXD CHARACTER OF FOOD NECESSARY. 87 

potatoes, in order to get enougli nitrogenous food, he would have 
to eat daily 8 kilogrammes. No human stomach could prove 
equal to the task of digesting this excess of material. On the 
other hand, it is to be noted how perfect the combination of the 
various principles is in human milk. In cows' milk, which is 
nearest in composition to human milk, tlie non-nitrogenous 
principles are deficient. Hence, the important practical point 
that when ordering milk diet for a patient a small portion of 
carbonaceous food (bread, rice, or sugar) must be added if the 
standard of health shall be reached or maintained. 

Climate has probably very little influence upon the amount 
of food required by the individual. The actual quantity of food 
consumed varies Httle between various races or in different parts 
of the earth. It is true, however, that a larger proportion of fat 
is required in cold cHmates. That fatty articles of food readily 
undero^o oxidation and furnish a laro:e amount of animal heat is 
proven both by observation and experiment. 

The albuminoid proximate principles of the food, proteids, 
are represented by the nitrogenous constituents of organic 
tissues. These are the vitellin and albumin of eggs, albumin, 
fibrin, globuhn, myosin, spitonin, and other nitrogenized prin- 
ciples of flesh and blood ; the casein of milk, the gluten, fibrin, 
and legumin of cereal and legummous seeds and plants, gelatin, 
and chondrin. 

Fat constitutes an integral component of animal tissue, and 
is found in abundance as a constituent of nerve-tissue, marrow, 
and subcutaneous connective tissue. In food it is represented 
especially in the fatty tissue of meat, the yelk of eggs, butter, 
etc. 

The carbohydrates are represented especially by various 
products of the vegetable world, as sugar, starch, dextrin, etc. 

Water and the various other inorganic proximate princi- 
ples, chief among which are compounds of calcium, sodium, and 
potassium, are usually found m sufficient proportion in the other 
alimentary substances. 



88 TEXT-BOOK OF HYGIENE. 

The food should be taken in appropriate quantities and 
properly prepared. A larger quantity than necessary may over- 
tax the digestive organs and thus yield less than the required 
amount of nutritive material to the body. 

Physical exertion increases the consumption of fatty prin- 
ciples. Hence, as in the cases of the athlete or prize-fighter in 
training, larger quantities of these principles are required to keep 
the nutrition of the body at the standard of health. During 
mental work, however, less carbohydrate material is consumed 
than during physical labor. 

The greater consumption of carbohydrates during muscular 
exercise is shown by the following table, which gives the amounts 
of carbon dioxide and nitrogen excreted by a man at rest and 



during labor : — 


Table X. 






CO2 Excreted. 


Nitrogen Excreted. 


At rest 

At work 


2.1 per cent. 

2.6 " " 


1.1 per cent. 
1.1 " " 



In youth the processes of combustion (production of carbon 
dioxide) go on with greater rapidity than after adult life is 
reached. For this reason young persons rarely get fat, the fat- 
producing food being burnt up in the body by the greater meta- 
bolic activity of the young cell. Hence, fats and carbohydrates 
should form a larger relative proportion in the diet of the young 
than in that of grown persons. 

Low external temperature causes a greater and more rapid 
consumption of fat than high external temperature. During 
febrile conditions, however, the destruction of stored-up fat in the 
body — the wasting away — is one of the most notable phenomena ; 
lience the importance of supplying fat and fat-producing food 
in chronic febrile diseases. 

"Der Mensch ist was er isst^^^ said Ludwig Feuerbach.^ 

' Gottheit, Freiheit und Unsterblichkeit von Standpunkt der Antbropologie, p. 5. 



CLASSinCATIOX OF FOODS. 89 

The pungency of the epigram is somewhat lost in the transla- 
tion, which is, literally. -Man is what he eats.'' The intimate 
relations of mental, moral, and physical conditions of health to 
the quaUty and quantity of food deserve the earnest attention 
of the educated physician and sanitaiian. 

CLASSIFICATIOX OF FOODS. 

Foods and victuals are generally divided into foods proper 
and so-called accessorv* aliment. The classification is not exact, 
however, as the latter, which are commonly regarded as articles 
of luxury, may under certain circumstances hecome necessities, 
and hence should not be considered as foiming a separate class. 

Toods are either of animal or vegetable origin. Those de- 
rived from animal sources are milk, the liesh of animals, birds, 
reptiles, and fish, and the eggs of the three last named. 

The foods derived from the vegetable kingdom comprise 
the seeds of various plants (cereals, legumes), roots, herbs, ripe 
fruits, the fleshy envelopes of various seeds (which may prop- 
erly be classed with the fruits), and various fungi. 

There are also in common use a number of beverages, e.g., 
water, alcoholic hquors. alkaloidal infusions (tea. coffee, cocoa). 
etc. 

In addition, a number of substances or compounds are in 
common use as condiments. Their function is either to render 
rictuals more palatable, or to promote digestion and assimilation. 
Vinegar, mustard, and common salt are familiar examples. 

FOODS OF AXDIAL OEIGIX. 

JliUc'. — Human milk is. so far as known, the one perfect 
food for man foimd in nature. It contains, in proper proportion, 
representatives of all the different classes of proximate principles 
necessary to nutrition. One hundred parts contain about '2.5 
parts of proteids (casein and albumin) ; 3.9 parts of fat (butter); 
6.0 parts of sugar, and .5 of salts. The reaction of human 
milk is slio:htlT alkaline; that of fresh cows* milk is neutral. 



90 TEXT-BOOK OF HYGIENE. 

In human milk there are 12.9 parts of solid matter to 87.1 
of water, while in cows' milk the proportions are: Proteids, 4.0 
per cent.; fats, 3.4 per cent.; sugar, 3.8 per cent.; salts, 0.6 per 
cent., or 11.8 total solids and 88.2 water.-^ 

Of the solids in milk, cows' milk contains more proteids, 
while human milk is richer in fats and sugar. Hence, in using 
cows' milk as a substitute for human milk the proteids are di- 
luted by the addition of water, and the non-nitrogenous com- 
ponents increased by adding sugar and, under some circum- 
stances, fat (cream). 

Goats' and asses' milk are sometimes used as substitutes 
for human milk, but they do not approach much nearer in com- 
position to the latter than does cows' milk. 

On standing, the fatty constituent of milk, the cream, sepa- 
rates, and on account of its less specific gravity rises to the 
surface, where it forms a layer of varying thickness. 

After standing a longer interval the milk undergoes certain 
physical and chemical changes. Lactic acid is formed at the 
expense of part of the sugar of milk (a sort of fermentation 
taking place), and, acting upon the casein, produces coagulation. 
This is the so-called " bonny-clabber." When the fermentation 
continues, especially under a slightly elevated temperature, the 
solid portion becomes condensed (curd), and a sweetish-acid, 
amber-colored liquid, the whey, separates. The curd, after 
further fermentation, under appropriate treatment, becomes 
converted into cheese. 

Whey is sometimes used alone or mixed with wine as an 
article of diet for the sick. 

Butter is made from the cream by prolonged agitation in a 
churn. The fat-globules adhere to each other and form a soft, 
unctuous mass, of a yellowish color, solid at ordinary tem- 
peratures. After the butter is all removed in this way the 
balance of the cream remains in the churn as buttermilk. This 
is an article of considerable nutritive value, although its excess 

» Average of a number of analyses. 



FOODS OF ANIMAL ORIGIN. 91 

of acid renders it unsuitable as an article of diet in many 
cases. 

The specific gravity of fresh milk should not be below 
1030. It should, however, be borne in mind tliat the richest 
milk is not always that which has the highest specific gravity. 
In fact, a sample of rich milk, containing a large proportion of 
cream, may show, when tested with the lactometer, a lower 
specific gravity than a specimen of much poorer milk. Hence, 
the lactometer, although a useful instrument in guarding against 
excessive dilution of the milk with water, is not a very trust- 
worthy guide in determining the quality of the milk. 

Objections are oflen urged against the use of so-called 
" skim-milk," ^.e., milk from which the cream has been removed. 
In some cities in this country the police, or representatives of 
the sanitary authorities, seize and confiscate all skim-milk found 
in possession of dealers. There appears to be no rational basis 
for the opmion held by many that skim-milk is not a proper 
and useful article of food. Before the lactic-acid fermentation 
has taken place it differs from fresh milk merely in the fatty 
and other matters removed in the cream. It contains nearly all 
of the proteids, sugar, and salts of whole milk, and may be used 
as an article of food with great advantage and entire safety. In 
certain diseased states it is of exceptional value as an article of 
diet. The sole objection of any ^veight to skim-milk is that it 
may be at times sold fraudulently as fresh milk. This is, how- 
ever, a question of little sanitary interest, but one prmcipally of 
commercial ethics. 

Milk is frequently adulterated by the addition of water. 
More deleterious substances are rarely found. An excess of 
water gives the milk a bluish tinge and reduces its specific 
gravity. The addition of water may become especially dangerous 
by introducing the virus of some of the acute infectious diseases. 
Thus, the localized epidemics of typhoid and scarlet fevers have, 
in quite a number of instances, been traced to mixing the milk 
with water contaming the poison of these diseases. It should, 



92 TEXT-BOOK OF HYGIENE. 

however, be stated that milk which contains the virus of typhoid 
fever has not necessarily been adulterated by the addition of 
water. The poison may have been introduced with the water 
used in washing the can, and adhered to the sides of the latter. 
In filling the can with milk a good culture medium is supphed 
in which the typhoid bacillus flourishes. 

It has long been a mooted question whether acute or chronic 
infectious diseases of the milk-giving animal may be communi- 
cated to persons using the milk of such animals. While there 
is little positive knowledge upon the subject, it would seem 
prudent to avoid the use of milk from diseased animals, if pos- 
sible, or to destroy any organic virus the milk may contain by 
previously boiling the milk. After thorough boiling little fear 
need be entertained of communicating either acute or chronic 
infectious diseases through this medium. Demme and Uffel- 
mann have reported cases which seem to demonstrate the pos- 
sibility of tuberculous infection through the medium of the milk. 
Professor Bang, of Copenhagen, has recently made a series of 
experiments and observations which has led him to the con- 
clusion that the milk of tuberculous cows and tuberculous 
women, in which there are no lesions in the mammary gland, 
only exceptionally contains the contagium. Professor Bang at 
the same time, however, points out that the milk from tubercu- 
lous udders is extremely dangerous, and that the tubercle bacilli 
are to be found not only in the milk itself, but in the cream, 
buttermilk, and butter made from it; and that such milk is 
sometimes infective by ingestion, even after exposure to 65° C. 
of heat, and by injection into the peritoneal cavity after exposure 
to 80° C. 

The infectiousness of the milk of cows suffering from 
splenic fever (milzbrand, anthrax) has been proven by Bollinger 
and Feser. Anthrax bacilli have been found in such milk by 
Chambrelent and Moussons. 

The agency of milk in the spread of scarlet fever is well 
recognized, but the manner in which the contagium gained 



FOODS OF ANIMAL ORIGIN. 93 

access to the milk was not well understood. Recently, however, 
an mcident happened m England which seems to prove a close 
connection between this widespread and fatal disease and a dis- 
order in the milk cattle. The evidence in support of this view is 
as follows : Mr. W. H. Power, of the Enghsh Local Government 
Board, was detailed to investigate certain outbreaks of scarlet 
fever which seemed to have especial relation to the milk-supply 
from a particular dairy-farm. Upon inspection this dairy was 
found to be in excellent sanitary condition as regards cleanliness, 
water-supply, sewerage, etc., and for a time considerable difficulty 
was experienced in locating the cause of the outbreaks. Im- 
probable as it may at first sight appear, it seems to have been 
incontestably established that the epidemics of scarlatina were 
due to the use of milk obtained from cows attacked by a peculiar 
disease manifested by a vesicular eruption followed by ulceration 
of the udder. The chain of circumstances connecting the dis- 
ease in the cows with the outbreaks of scarlet fever in certain 
districts in London, supplied with milk from the diseased cows, 
w^as so strongly forged by the able investigator, into whose hands 
the w^ork had been committed by the authorities, that hardly a 
doubt can exist that the one disease owed its origin to the other. 

The pathological evidence furnished by Dr. Klein lends 
strong support to the view that the Hendon cow disease and 
scarlet fever are intimately related to each other. A bacterial 
organism was found in the material from the ulcerated udders 
of the sick cows, which presents similar characters to a micro- 
coccus found by the same observer in the blood of scarlet-fever 
patients. These results require more extended investigations 
before they can be unreservedly accepted. 

The milk of cows fed upon the refuse of breweries and dis- 
tilleries — "swill-milk" — is believed by many physicians to be 
unwholesome. If so, it is, probably, only by reason of the un- 
favorable hygienic conditions under which the animals are kept. 
If the stables are clean, dry, and well ventilated, and the ani- 
mals receive plenty of fresh air and exercise, swill-fed cows 



94 TEXT-BOOK OF HYGIENE. 

should produce as nutritious milk as when they are fed upon 
different food. Much of the present agitation against "swill- 
milk" is more prompted by political demagogism than by 
scientific knowledge. 

The milk of animals suffering from certain diseases is oflen 
dangerous to health. In some of the Western and Southern 
United States, cows are not infrequently attacked by an acute 
febrile disease called " the trembles," from one of the prominent 
symptoms. The milk of cows suffering from this disease pro- 
duces severe gastro-intestinal disorder, collapse, fever, etc., in 
the consumer. This disease, called " milk-sickness," is fatal in 
a pretty large proportion of cases. It is said that the flesh of 
animals with "the trembles" will, if eaten, produce similar dan- 
gerous effects. A late writer (Dr. Beach, of Ohio) estimates 
that 25 per cent, of the Western pioneers and their families 
died of this disease. 

For the ready determination of the quality of milk, instru- 
ments known as lactoscopes, lactometers, and creamometers are 
used. The lactoscope indicates the opacity of the milk, upon 
which the proportion of cream depends. One convenient mod- 
ification of the lactoscope is the little instrument termed the 
pioscope. This consists of a disk about 6} centimetres in diam- 
eter, with a slight depression in the centre. A little milk is 
placed in the depression and covered with a glass disk, clear 
in the centre and opaque around the border, which is divided 
into six divisions of different shades, varying from white to 
dark gray. The quality of the milk is marked upon the 
division whose color corresponds with that of the milk in 
the centre. 

A better, but still not very accurate, indicator of the quality 
of the milk is the creamometer. This consists of a cylindrical 
glass vessel with the upper half divided up into hundredths. 
The glass is filled up to the zero mark with milk, and allowed 
to stand until all the cream has separated. The thickness of 
this layer is then read off on the scale. In Chevallier's instru- 



FOODS OF ANIMAL ORTGIX. 



95 




■"im 



meiit, 10 per cent, of cream is the minimum proportion that 
should be furnislied by the milk. 

The specific gravity, which is a fair guide to the quality of 
the milk, with the reservations above mentioned, is measured by 
means of the lactometer or lactodensimeter. The specific 
gravity of good cows' milk should not be less than 1029. 

In order to prevent the rapid fermentation of milk various 
methods of preservation have been adopted. The addition of 
alkahes, or antiseptics, retards the lactic-acid feimentation, while 
the abstraction of a portion of 
the water and addition of sugar 
(condensed milk) preserves it 
for an indefinite time. The 
mere addition of water restores 
it to nearly its original condition. 

Tyrotoxicon in 2HIl\ — This 
substance, first found in poison- 
ous cheese, and later in milk, ice- 
cream, custards, etc., is believed 
by Professor Yaughan to be the 
cause of true cholera infantum, 
and many of the clinical phe- 
nomena of this disease lend 
strong support to such a view. 
The conditions under which the 
poison is developed have not yet 
been sufficiently studied to enable correct conclusions to be drawn. 

Butter. — Butter is of especial value as food on account of 
the large amount of easily digestible fat which it contains. It is 
almost always used as accessory to other articles of food, to ren- 
der them more palatable. When pure and fresh, it is one of the 
most dehcious of creature comforts. It soon undersfoes the 
but^Tic-acid fermentation, however, becomino^ "rancid." as it is 
termed, when it is unfit for food. 

The great demand for butter and its consequent high price 



mm 



m 




Fig. 3.— Chzyalliek's Ckea^ioxetek. 



96 TEXT-BOOK OF HYGIENE. 

have led to its extensive sophistication. Butter is now very 
largely substituted by an artificial product termed oleo-margarine, 
or butterine. This artificial butter is made from beef-suet by the 
following process : Fresh beef-fat is melted at as low a temperature 
as possible, never higher than 52° to 53° C. [126° to 128° F.]. 
All membrane and tissue are then removed, and the resulting 
clear fat is put into presses, where the stearine is extracted. 
The liquid fat, free from tissue, and with nearly all its stearine 
removed, is known as "oleo-margarine oil." The next step 
in the process is " churning." The oil is allowed to run into 
churns containing milk and a small quantity of coloring 
material (annatto), where, by means of rapidly-revolving pad- 
dles, it is churned for about an hour. When this part of the 
process is complete, the substance is drawn off" from the 
bottom of the churn into cracked ice. When cool it is taken 
from the ice, mixed with a proper quantity of salt, and is then 
worked like butter and put into firkins for the market. It is 
also molded into attractive prints in imitation of dairy-butter.^ 
When the materials from which oleo-margarine is made are 
sweet and clean, and when the process of manufacture is prop- 
erly conducted, the resulting product is an entirely harmless 
article, and probably difiers very Httle in nutritive value from 
butter itself 

Cheese. — The value of cheese as a food depends upon the 
large amount of proteids and fat which it contains. The rich 
varieties of cheese, such as Fromage de Brie and Roquefort, con- 
tain on an average 30 per cent, of fat and 27 per cent, of proteid 
compounds. Parmesan contains only about 8 per cent, of fat 
and nearly 33 per cent, of proteids, while Edam and Chester 
cheese, which may be considered as standing about midway 
between the above, contain 20 per cent, of fat and nearly 28 
per cent, of proteids. From these figures it appears that cheese 
is one of the most nutritious aliments obtainable, but it cannot 

» Dr. W. K. Newton, Fifth Annual Report of the State Board of Health of New Jersey, 
1881, p. 107. 



FOODS OF ANIMAL ORIGIX. 



97 



be eaten in large quantities at a time, as it is exceedingly liable 
to cause disturbances of the digestive organs. The constipating 
property of cheese is well known to the public. 

The relative value of different kinds of cheese in alimentary 
principles is given in the following table: — 

Table XI. 



KiKD OF Cheese. 


Proteids 

(per cent.). 


Fats 
(percent.). 


Sn^r 
(per cent). 


Salts 
(per cent). 


Cheshire 

Edara 

Holland 

Roquefort 

Neufcbatel 

Parmesau 


27.68 
24.07 
29.48 
27.69 
17.44 
41.19 


27.46 
30.26 
26.71 
33.44 
40.80 
19.52 


5.89 
4.48 
2.27 
3.15 
5.21 
1.18 


5.01 
4.91 
4.62 
5.35 
2.05 
6.31 



Cheese is not often adulterated. The only articles used 
with success in its sophistication are lard and oleo-margarine, 
which are incorporated with the casein during the process of 
manufacture. It sometimes undergoes chemical changes which 
render it intensely poisonous when eaten. 

Prof. V. C. Vaughan, of the University of Michigan, has 
ascertained that the substance causing the poisonous symptoms 
is a chemical compound termed by him tyrotoxicon. This 
same poison has also been found by Professor Vaughan and 
other chemists in ice-cream and fresh milk, which produced 
poisonous symptoms when consumed. The poison is supposed 
to be a ptomaine produced by the agency of a micro-organism, 
which has, however, not yet been isolated. 

Meat. — The flesh of mammals, reptiles, birds, fish, and 
invertebrate animals is used as food by man. Falck^ has classi- 
fied the varieties of animals which furnish food to the inhabitants 
of Europe. There are 47 varieties of the mammalian class, 
105 of birds, 7 of amphibia, 110 of fish, and 58 of invertebrates. 

^ Das Fleisch, Gemeinverstsendliches Handbuch der Wissenscbaf tliclien und Praktisclien 
Fleiscbkunde. 

7 



98 



TEXT-BOOK OF HYGIENE. 



Meat is the most important source of proteids in the food. 
In the more commonly used varieties of meat the proteids and 
fats constitute from 25 to 50 per cent, of the entire bulk, the 
proportion depending largely upon the age of the animal and its 
bodily condition. The following table shows the influence of 
these two factors upon the relative proportions of the fats and 
proteids contained in the meat: — 

Table XTI.i 



Moderately fat beef 
Lean beef . . . . 

Yeal 

Very fat mutton 
Fat pork . . . . 
Lean pork . . . . 

Hare 

Lean chicken . . . 



Proteids (percent.). 



21.39 
20.54 
10.88 
14.80 
14.54 
19.91 
23.34 
19.72 



Fats (percent.). 



5.19 

1.78 
7.41 
36.39 
37.34 
6.81 
1.13 
1.42 



The flesh of animals, which is neutral in reaction immedi- 
ately after death, soon becomes acid in consequence of the 
formation of lactic acid. The acid, acting upon the sarcolemma 
and the muscular fibre, renders it softer and more easily per- 
meable by fluids when cooking, and more susceptible to the 
action of the gastric juice when the meat is taken into the 
stomach. 

Certain kinds of meat — mutton and venison, for example — 
are often kept so long before being eaten that a considerable 
degree of putrefaction has taken place when they are brought 
upon the table. The wisdom of this practice is questionable 
from a hygienic point of view. 

Meat is sometimes eaten raw, but it is usually first cooked. 
The methods of cooking in general use are boiling, frying, 
roasting, broiling, and baking. By either of these methods of 



* Abridged from Loebisch ; article "Fleiscb" in Realencyclopaedie d. ges. Heilkuude, 
vol. V, p. 340. Fuller details will be found in Table VIII. 



FOODS OF ANIMAL ORIGIN. 99 

cooking, when properly carried out, the nutritious properties of 
tlie meat are preserved, and it is rendered digestible. The 
culinary art deserves the closest attention of students of hygiene. 

A number of soluble preparations of meat (beef-extract, 
beef-essence, beef-juice) are found in the market, and highly 
recommended as containing all the nutritious qualities of the 
meat from which they are prepared. These, and similar products 
of domestic preparation (broths and teas), contain in reality 
very little nutritive material, but are of use almost solely as 
stimulants to the appetite and digestion. They have a place in 
the dietary of the sick, but their nutritive value is small. 

On the other hand, a number of partly or wholly predi- 
gested (peptonized or pancreatized) preparations of meat are 
offered for sale, many of which have a high nutritive value. 
They cannot, however, be used as articles of diet except for a 
short time, or as a temporary succedaneum for meat in diseases 
attended with weakness or derangement of the digestive organs. 

Meat may be unfit for food from various causes. Thus 
the flesh of animals dying from certain diseases — splenic fever, 
pleuro- pneumonia, tuberculosis in its advanced stages, cow- or 
sheep- pox — should not be used as food when it can be avoided. 
Cases are on record proving the poisonous character of meat 
from animals which suffered, at the time of death, from some of 
the above-mentioned diseases. The most important condition 
to be borne in mind is that certain parasites (trichina spiralis, 
echinococcus, cysticercus), which frequently infest the flesh of 
animals, especially hogs, not infrequently give rise to serious or 
even fatal diseases in persons consuming such meat. Any meat 
containing these parasites, or suspected of containing them, 
should therefore not be used as food unless precautions be first 
taken to destroy the life of the parasite. 

Of the parasites mentioned the trichina spiralis is the most 
important in this connection, as it frequently occurs in the fiesh 
of hogs, rats, dogs, cats, and other carnivorous animals. Rats 
are said to be infested with the parasite more frequently than 



100 TEXT-BOOK OF HYGIENE. 

any other animals. The trichmse are found m two forms, one, 
the mature form, mhabiting the mtestinal canal. The immature 
form, or muscle trichinae, are found in striped muscle, coiled into 
spirals and encysted in a fibrous capsule. They gain access to 
their host in the following manner: Flesh containing living 
trichinae is taken into the stomach, where the muscular tissue 
and the fibrous envelope are dissolved, and the inclosed worms 
set free. These mature in the intestinal canal, where sexual 
reproduction takes place, and the young embryos pass through 
the intestinal walls and other tissues until they become imbedded 
in striated muscle. Localized epidemics of trichinosis have 
been reported in this country and Europe, and in nearly every 
instance the source of the disease has been traced to the inges- 
tion of uncooked pork. Meat known to be trichinous should 
not be used unless in times of great scarcity. It may, however, 
be rendered innocuous by thorough cooking. A temperature 
of 60° to 70° (140° to 160° F.) destroys the life of the parasite 
and renders the meat safe. On account of the frequent occur- 
rence of trichinae in pork, this meat should never be eaten unless 
thoroughly cooked. It has been ascertained that salted and 
smoked pork is not free from danger, as the parasites are not 
killed in the process of curing the meat. Hence, ham and 
sausage should not be eaten raw, as the danger from these 
articles is almost equally as great as from fresh pork. 

Gysticercus cellulosa, the transition form of one variety of 
tape-worm, and which is the parasite in measly pork, may also 
gain entrance to the human body, and, failing to undergo devel- 
opment, cause very serious lesions of various organs and tissues. 
The frequency of tape- worm is evidence that pork is often thus 
diseased. i 

The use of partially decayed meat or fish has often been 
the cause of serious or fatal illness. Sometimes the illness par- 
takes of the character of septic infection. In these cases it is 
probable that the morbid process is due to the action of the 
organisms of putrefaction. In other cases the symptoms are 






FOODS OF ANIMAL ORIGIN. 101 

widely different. These cases have been the source of much 
perplexity to physicians and toxicologists until very recently. 
Within the past six years, however, Selmi, Husemann, Brouardel, 
Casali, and others have drawn attention to certain intensely 
poisonous chemical compounds found in decomposing flesh, and 
which have been named by Selmi ptomaines. While there is 
still much uncertainty concerning the nature of these compounds, 
it seems pretty wtII established that when flesh undergoes de- 
composition, m the absence of oxygen, certain unstable chemical 
combinations are formed which act as violent poisons. Selmi, 
followed by most toxicologists, believes these compounds to be 
alkaloids, analogous to the vegetable alkaloids, such as morphine, 
atropine, etc. Casali, on the other hand, disagrees with this 
opinion, and behoves the ptomaines to be amido compounds. 
Husemann regards Casah's hypothesis as plausible, inasmuch as 
the formation of amido compounds in animal and vegetable 
bodies during decomposition is well established. 

The form of poisoning due to the organisms of putrefaction 
is not infrequent. An extensive outbreak of this nature occurred 
at Andelfingen, in Switzerland, in 1839. A musical festival 
was held, -at which there were over 700 present. Out of these 
444 were suddenly attacked by violent gastro-enteric and nervous 
symptoms. Ten of the patients died. The illness was traced to 
roast veal, which had been kept in a warm place for two days 
after roasting, and w^hich was probably in a state of partial 
decomposition. 

The class of cases which seem more probably due to the 
action of ptomaines or related poisons, have been frequently 
observed after eating sausages or canned meats. Sausage poi- 
soning is not rarely observed in Germany. It has been ascer- 
tained that the internal portions of the sausage are the most 
poisonous. It is supposed that the ptomaines, which are formed 
in the absence of oxygen, are the active agents in the pro- 
duction of the train of symptoms. Poisoning by canned meat 
seems to be due to a similar poison. 



102 TEXT-BOOK OF HYGIENE. 

In July, 1885, an outbreak of disease, due to eating un- 
wholesome beef, was caused at Momence, Illinois. Chemical 
examination of specimens of the meat showed the presence of 
an alkaloidal body, which was believed to be a ptomame, but its 
nature was not definitely determined. 

Fish, oysters, crabs, and lobsters frequently give rise to 
symptoms of poisoning. In most of these cases the poisoning 
is probably due to partial decomposition, but it is a well-known 
fact that oysters and crabs are unfit for food at certain seasons. 
Some persons, however, are subjects of a peculiar idiosyncrasy, 
in consequence of which shell-fish always produce certain un- 
pleasant symptoms, among which nettle-rash and a choleraic 
attack are most prominent. 

That form of fish-poisoning known among the Spaniards 
in the West Indies as siguatera is, however, very grave. The 
mortality is large, and in many cases death succeeds rapidly 
upon the attack. The symptoms are as follow: Sometimes 
suddenly, sometimes preceded by dizziness and indistinct vision, 
great prostration and paralysis occur. Often death follows the 
onset of the symptoms in two and three hours ; exceptionally in 
less than twenty minutes. In most cases consciousness is totally 
lost; in others it persists, with interruptions, until death. Sensa- 
tion and the powers of speech and deglutition fail. The jaw- 
muscles become paralyzed, the pulse is slowed, and the tem- 
perature diminished. There is sometimes vomiting, but no 
purging. The secretion of the kidneys is also checked. Dr. 
McSherry states^ that he has seen all these symptoms produced 
by eating oysters, lobsters, and crabs unseasonably. 

In Russia a form of poisoning has often been observed 
which results from eating salted sturgeon. In the fresh state 
these fish are perfectly wholesome, but when salted and eaten 
raw they produce a very fatal illness. The mortality is said to 
reach 50 per cent, of those attacked. No cases traceable to 
this cause have been observed in this country. 

1 Health and How to Promote it, p. 143, 






FOODS OF ANIMAL ORIGIN. 103 

It lias been shown, beyond question, that the flesh of beeves 
suffering, when killed, from splenic fever, will produce this 
disease in the human subject. 

In 1871 an extensive and violent outbreak of an acute 
disease, characterized by vomiting and purging, fever and dizzi- 
ness, occurred at Middelburg, in Holland. Three hundred and 
forty-nine persons were attacked, of w^hom 6 died. The out- 
break was traced to eating liver-sausage (Leber wurst), in which 
the characteristic bacillus of splenic fever was found on micro- 
scopic examination. In July, 1877, an outbreak of choleraic 
disease, from eating carbuncular meat, occurred in the town of 
Wurzen. In the latter epidemic the bacillus of splenic fever 
(Bacillus anthracis) was found in the intestinal canal and in the 
blood of those attacked. 

In Detmold, in Germany, an outbreak of violent gastro- 
intestinal inflammation, accompanied by high fever, occurred. 
Among the 150 persons attacked 3 died. The disease was 
traced to eating the meat of a cow sufl"ering, before death, 
from pleurisy (probably pleuro-pneumonia). In view of the 
somewhat extensive prevalence of this disease among cattle in 
this country at the present time, the record of this outbreak may 
suggest to sanitary authorities some measures for the prevention 
of similar epidemics on this side of the Atlantic. 

In July, 1880, 72 persons w^ho had eaten of certain beef 
and ham-sandwiches in Welbeck, England, w^ere attacked by 
choleraic diarrhoea; 4 of the cases died. Inflammation of the 
lungs and small intestines were the most prominent pathological 
conditions found post-mortem. The smaller blood-vessels of the 
kidneys were filled with finger-shaped bacilli, which, when cul- 
tivated and inoculated into guinea-pigs, rats, and white mice, 
produced similar pathological conditions. At Nottingham, 
England, in 1881, a number of persons were attacked by a 
similar train of symptoms after eating baked pork. One case . 
terminated fatally out of the 15 attacked. It is uncertain 
whether the meat in these two instances was from diseased 



104 TEXT-BOOK OF HYGIENE. ; 

animals or whether it had undergone partial decomposition. 
The former is the more probable supposition, although the 
organisms found were neitlier those of splenic fever nor swine 
plague, but resembled those of symptomatic anthrax (black leg 
or black quarter). 

Whether the flesh of tuberculous animals can communicate 
tuberculosis to the consumer is still an unsettled question. 
Foreign veterinarians and hygienists who have studied the 
question incline to the view that there is danger of such trans- 
mission. At the International Sanitary Congress of 1883, at 
Brussels, the subject was discussed, and M. Lydtin, the chief 
veterinary surgeon of the Grand Duchy of Baden, submitted 
the following propositions, which were adopted by the Congress : 

1. That the flesh and viscera of tuberculous animals may 
be used as food, provided the disease is only commencing, the 
lesions extending but to a small part of the body, the lymphatic 
glands being still healthy; provided the tubercle centres have 
not undergone softening, and provided the carcass is well nour- 
ished and the flesh presents the characters of meat of the iirst 
quality. 2. That the flesh of animals showing very pronounced 
tuberculous infection should be saturated with petroleum, and 
afterward burned under the direction of the police. 3. That the 
milk from cows affected with pulmonary phthisis, or suspected of 
having it, should not be consumed by man or other animals, 
and the sale of it should be strictly prohibited. 

The congress for the study of tuberculosis, which met in 
Paris in 1888, adopted resolutions of a more decided character 
against the use of meat and milk from tuberculous animals. 

Certain animals can devour with impunity substances 
which are intensely poisonous to human beings. The flesh of 
the animals may be impregnated with these poisons, and cause 
serious and fatal illness in persons partaking of it. In this way 
may, perhaps, be explained the cases of poisoning sometimes 
following the eating of partridges and other birds. 

The prevention of disease from tainted meat is one of the 



FOODS OF AXIMAL ORIGIN. 105 

most important problems of public hygiene. Food animals 
should be inspected by qualified inspectors before slaughtering, 
to exclude animals suffering from diseases that would vitiate the 
meat. When the meat is exposed for sale upon the dealer's 
stall it should be again inspected, and all found unfit for use as 
food confiscated and destroyed. Meat, in which the presence 
of trichinae or other parasites is suspected, should be examined 
microscopically.^ 

Eggs. — Although eggs contain a large amount of the pro- 
teid and fatty alimentary principles," their value as food has 
probably been greatly overrated. The savory taste and ready 
digestibility of eggs has, however, rendered them a popular 
article of food. For obvious reasons, the eggs of the common 
bam-yard fowl are most frequently used, those of ducks and 
o^eese beins^ far inferior in flavor to the first named, and beino: 
likewise less easily obtained. 

The method of cooking eggs is generally supposed to have 
considerable influence upon their digestibility. According to 
Dr. Beaumont's experiments made on Alexis St. Martin, raw^ 
eggs are digested in one and a half to two hours, fresh-roasted 
in two hours and fifteen minutes, soft-boiled or poached in three 
hours, and hard-boiled or fried in three and a half hours. These 
experiments are, however, of very little value as a basis for 
general conclusions. It is probable that a hard-boiled e^g is 
quite as easily digested in the healthy stomach as a raw one, if 
care be taken to masticate it well and eat bread with it, so that 
it is introduced into the stomach in a finely-divided state. 

Eggs readily undergo putrefaction, when sulphuretted 
hydrogen is formed in them in large quantities. AVhen tliis 
has taken place they are manifestly unfit to be used as food. 

^ The prevention of the diseases of animals by National and State authorities is one of 
the most logical and thorough-going means of preventing disease from unwholesome meat. The 
American Public Health Association has for some years devoted considerable attention to the 
investigation of the diseases of animals and means for their prevention. The Department of 
the Interior of the National Government has likewise made the diseai^es of cattle and hogs a 
subject of study and published some valuable reports thereon. 

2 See analysis in Table VUI. 



106 TEXT-BOOK OF HYGIENE. 

FOODS OF VEGETABLE ORIGIN". 

Bread. — The various cereal grains, when ground into flour, 
are used in making bread. The flours of wheat, rye, barley, 
buckwheat, and Indian corn are almost exclusively used in bread- 
making. The bran or cortical portion of grain contains a larger 
. percentage of proteid principles than the white internal portion ; 
hence, flours made from the whole grain (bran-flour, Graham 
flour) if finely ground are more nutritious than the white flours. 
The latter are, however, more digestible, and hence furnish a 
larger proportion of nutriment, because the principles contained 
in white flours are absorbed and assimilated to a greater degree. 

Good bread should be light, porous, and well baked. The 
lightness and porosity are due to carbon-dioxide gas imprisoned 
in cavities of the dough during the process of bread-making. 
By adding yeast to the dough a fermentation is caused in the 
latter, in consequence of which a portion of the starch is con- 
verted into sugar, and then into alcohol and carbon dioxide. 
During the process of mixing the dough the entire mass becomes 
permeated by the gas, which, on heating, expands and leaves 
the numerous large and small cavities throughout the loaf which 
indicate properly-made bread. 

Instead of yeast some persons use leaven, which is simply 
a portion of fermenting dough, saved from previous baking. A 
small quantity of this added to a mass of dough starts up the 
fermentation in a similar manner to that of yeast. 

The production of carbon dioxide by fermentation in the 
dough goes on at the expense of part of the starch. It has 
been proposed, therefore, to supply the carbon dioxide from 
without, thus saving the entire amount of the carbohydrates 
present in the flour. This is accomplished in two ways — 
first, by the use of some alkaline carbonate or bicarbonate 
(bicarbonate of sodium, carbonate of ammonium), the carbon 
dioxide being set free on the application of heat ; or, secondly, 
by forcing the gas, previously prepared, into the dough by means 
of machinery. 



FOODS OF VEGETABLE ORIGIN. 



107 



Flour is not infrequently adulterated with chalk, gypsum, 
pipe-clay, and similar articles. These are easily detected by 
adding a mineral acid, which produces effervescence when it 
comes in contact with the alkaline carbonate used as adulterant. 
Potato- and bean- meals are also used as adulterants of the higher 
grades of flour. Bakers often mix alum with inferior grades of 
flour. This imparts a greater degree of whiteness to the bread, 
and, in addition, enables it to retain a large proportion of water, 
thereby increasing the weight of the loaf. 

Formerly diseased grain (ergotized rye) often caused out- 
breaks of disease when the flour made from the diseased grain 
was used in bread-making. At the present time such accidents 
rarely occur. In some parts of Italy it is said that an endemic 
disease — pellagra — is caused by the consumption of diseased 
Indian corn. The evidence in favor of this view is, however, 
not unquestioned. 

Potatoes and rice are often used with satisfaction as substi- 
tutes for bread. They both contain a large proportion of carbo- 
hydrates. Indian corn (hominy) and oatmeal are likewise 
wholesome and nutritious foods of this class. 

The leguminous seeds (beans, peas, lentils) furnish a food 
containing a large percentage of proteids. According to the 
analyses of Kcenig ^ the average composition of the most fre- 
quently used legumes in the dried condition is as follows : — 

Table XIII. 





Beans. 


Peas. 


Lentils, 


Ground-nuts.^ 


Water, per cent. . . . 
Solids, per cent. . . . 


13.6 

86.4 


14.3 

85.7 


12.5 

87.5 


6.5 
93.5 


Proteids, per cent. . . 

Fats 

Carbohj^drates, per cent. 
Cellulose, per cent. . . 
Ash 


28.1 
2.3 

53.6 
3.9 
3.5 


22.6 
1.7 

53.2 
5.5 

2.7 


24.8 
1.9 

54.7) 
3.6) 
2.5 


28.2 
46.4 

15.7 

3.2 



1 Die Menschlichen Nahrungs und Genussmittel, ii, p. 2SS. 

* The American pea-nut, the fruit or uut of Arachis hypogcea. 



108 TEXT-BOOK OF HYGIENE. 

Beans, peas, and lentils are often added to other articles of 
food with advantage. In recent years an important article of 
food for armies has been made of various legumes ground into 
flour and mixed with fat, dried and powdered meat, salt, and 
spice. This constitutes the so-called " Erbswurst," or pea-sausage, 
which formed such an important part of the dietary of the German 
army in the Franco-German war of 1871. Bean- and pea- meals 
are also used sometimes as additions to other flours in bread- 
making. The dried leguminous fruits cannot be used as regular 
articles of diet, however, as they soon pall upon the taste, and 
produce indigestion, nausea, and other intestinal derangements. 

Green Vegetables. — The plants usually classed together as 
" vegetables," the products of the market-garden or truck-farm, 
comprise cabbages, turnips, parsnips, onions, beets, carrots, 
tomatoes, lettuce, green peas and beans, and similar articles. 
They all contain a large proportion of water, a variable propor- 
tion of sugar, and a small percentage of proteid principles. 
Much of their palatability and digestibility depend upon the 
methods by which they are prepared for the table. All garden 
vegetables should be used soon after being gathered, as they 
rapidly undergo decomposition, and are liable to produce 
derangements of the digestive organs if used under these 
conditions. 

Fruits and nuts generally contain large quantities of sugar 
and fats. They form agreeable additions to other articles of 
diet, but are insufficient to sustain life. The use of fruits usually 
produces copious intestinal evacuations, and they are, therefore, 
especially to be recommended to persons of sedentary occupations, 
in whom torpidity of the bowels is so frequently present. 

Condiments. — Various aromatic herbs and seeds are used 
as additions to other articles of food, to increase their sapidity 
and to promote a larger flow of saliva and gastric juice, and so 
assist digestion. Mustard, pepper, allspice, and vinegar are the 
principal condiments. Within certain limits they are not in- 
jurious, but the tendency m the use of all stimulants is to 



COOKING. 109 

exceed a healthful limit. Condiments, as well as other stimu- 
lants, should be used in moderation. 

COOKING. 

Much more attention than is generally given should be paid 
by physicians to the culinary art. The manner in which food is 
cooked has no little influence upon its digestibility. There can 
be no question that the extreme prevalence of functional indi- 
gestion in tliis country is almost exclusively dependent upon bad 
cooking. 

The various methods of cooking are boiling, frying, roast- 
ing, broiling, and baking. By either of these methods food can 
be cooked so as to be palatable as well as digestible ; on the other 
hand, the choicest article can be utterly spoiled and rendered 
unfit to be taken into the human stomach. It depends, therefore, 
not so much upon the method of cooking, as upon the knowledge 
and art of the cook. 

Boiling. — Meats of all kinds are rendered tender and di- 
gestible by boiling. In order to retain the flavor of meat, the 
water should be boiling when the meat is put into it. By the 
heat of the boiling water the albumen on the outside of the 
meat is coagulated and the juices and flavor retained within. 
After a few minutes the temperature of the water should be re- 
duced to 71° to 77° C. (160° to 170° F.), and maintained at that 
height until the meat is tender. By this process a much more 
savory piece of beef, mutton, or fowl can be obtained than where 
the meat is put into cold water and thus gradually heated. The 
latter method is, however, the proper one to be followed when 
good soup or broth is desired. 

In boiling vegetables, as much care is necessary as in boil- 
ing meat or fish. Potatoes and rice should be steamed, rather 
than boiled. 

The difliculty of obtaining a good cup of coflee, especially 
in the northern portion of the United States, illustrates the pre- 
vaiHng ignorance upon one of the simplest points in the art of 



110 TEXT-BOOK OF HYGIENE. 

cooking. Coffee should never be served in the form of a de- 
coction; that is to say, it should never be boiled. Properly made 
it is an infusion, like tea, which no one ever thinks of boiling. 
The difference between an infusion (especially if made by per- 
colation) and a decoction of coffee can only be appreciated by 
those who have enjoyed the one and endured the other. 

Frying. — Frying, if properly done, is really nothing less 
nor more than boiling in oil or fluid fat of some kind. Olive- 
oil is preferable, but is not essential ; butter, beef-drippings, lard, 
or probably cotton-seed oil may be substituted for it without 
disadvantage. The principle of frying depends upon the fact 
that the temperature of oil can be raised to such a height as to 
produce instant coagulation of the surface of meat, fish, or other 
object immersed in it while hot ; this film of coagulated albu- 
men imprisons the juices and flavors of the meat or fish, and pre- 
vents the fat entering and soaking the fibres with grease. Small 
fish or birds, properly fried, are justly regarded as delicacies by 
connoisseurs, but the process of saturating these objects with fat 
while gradually heating them produces a dish that is anything 
rather than grateful to the palate, or conducive to good digestion. 

Roasting. — The fame of " the roast beef of Old England" 
has passed into song, but, at the present day, beef and other 
meats are rarely roasted, either in this country or abroad. As 
Sir Henry Thompson well expresses it,^ "the joint, which for- 
merly turned in a current of fresh air before a well-made fire, is 
now half stifled in a close atmosphere of its own vapors, very 
much to the destruction of the characteristic flavor of a roast." 
It is probable that the old method of roasting before an open fire 
produced not only the most savory, but likewise the most nu- 
tritious and digestible, meat. It is much to be regretted that the 
process has fallen so greatly into disuse. 

Broiling and Baldng. — These methods of cooking are 
modifications of the process of roasting. Meats or fish, care- 
fully broiled or baked, preserve their natural juices and flavors 

» Food and Feeding, p. 45. London, 1880. 



ALDIEXTAET EEVEKAGES. Ill 

to a great extent, and retain their digestibility and nutritious 
properties. Of all methods of cooking these are probably best 
known and most satisfactorily applied in this country.' 

ALLMEXTARY BE^TRAGES. 

The alimentaiy beverages may be divided into two classes, 
— those depending for their effects upon the alcohol they contain, 
and those whose active principles reside in certain alkaloids. 
They are used cliielly as digestive and nervous stimulants. 

BEVERAGES COXTAIXIXG ALCOHOL. 

The physiological action of alcohol has been pretty fully 
worked out by Binz and his pupils, and by other experimenters. 
From these researches, it appears that the first effect of taking 
alcohol, sufficiently diluted, into the stomach, is to increase the 
flow of the saliva and gastric juice. Tliis effect is probably re- 
flex, and results from a stimulation of nerve terminations hi the 
stomach. The alcohol is rapidly absorbed, and is carried in the 
blood, without undergoing chemical change, to the nervous 
centi'es. lungs, and tissues generally. In the braui the alcohol 
probably enters into combination with the nervous tissue, 
modifying the normal activity of the various centres, either 
mcreasing the activity, if the alcohol is in small quantity (stim- 
ulating effect), or diminishing it if in larger quantity (depressing 
effect), or enth'ely suspending the activity of the centi'es. if in 
sufficiently large quantity (paralyzing effect). 

Alcohol stimulates the vasodilator nerves, causing dilata- 
tion of the smaller vessels ; in consequence of this the blood is 
largely sent to the peripheiy of the body : the blood-pressure 
diminishes, and heat-radiation is increased. At the same time 
a portion of the alcohol is used up in the lungs in the produc- 
tion of animal heat, thus economizing the expenditure of fats 

* Erery one interested in the proper application of the principles of cookery should 
study the Lomb prize essay of the American Public Health Association, by Mary Hinman Abel, 
upon "Practical. Sanitary, and Economic Cooking." This little book can be obtained of Dr. L 
A. Watson. Secretary. Concord, X. H. : price. 25 cents. See. also, an essay on ••The Art of Cook- 
ing.'" by Edward Atkinson. LLD., in Popular Science Monthly. ^Tovember. 1559. 



112 TEXT-BOOK OF HYGIENE. 

and proteids, and acting as a true respiratory food. Alcohol 
does not contribute nutritive material to the body ; it only per- 
mits that which is stored up to be saved for other uses, by fur- 
nishing easily-oxidizable (combustible) material for carrying on 
the respiratory process, and supplying animal heat. 

During the use of alcoliol the excretion of urea is dimin- 
ished. This shows that waste of tissue is retarded in the 
body. 

Regarding the statement of some authorities that alcohol does 
not undergo any change in the body, but is excreted unchanged, 
Binz asserts^ that alcohol appears in the urine only when 
exceptionally large quantities liave been taken, and then in very 
small proportion. It is not excreted by the lungs, the peculiar 
odor of the breath being due not to the alcohol, but to the 
volatile aromatic ether, which is oxidized with greater difficulty, 
and so escapes unchanged. 

While alcohol produces subjectively an agreeable sensation 
of warmth in the stomach and on the surface of the body, the 
bodily temperature is not raised. The subjective sensation is 
due to the dilatation of the blood-vessels and the sudden hyper- 
semia of those parts. 

During fevers and other exhausting diseases, alcohol is 
invaluable to prevent waste of tissue and sustain the strength. 
It does not act merely as a stimulant to the circulation and 
nervous system, but, as above pointed out, saves the more stable 
compounds by furnishing a readily oxidizable respiratory food. 

When taken in small doses by healthy persons, alcohol 
diminishes the temperature by increasing heat-radiation. When 
large quantities are taken, the bodily temperature is reduced by 
diminishing heat production, as well as by increased radiation. 
This is shown in the condition known as dead-drunkenness, in 
which the temperature is sometimes depressed as much as 20 ° F. 
below the normal. Cases in which the temperature sank to 75°, 
78.8°, and 83° F. have been reported, with recovery in aU cases. 

* Realencyclopsedie d. ges. Heilk., Bd. I, p. 183. 



BEVERAGES CONTAIXIXG ALCOHOL. 113 

The constant use of alcohol produces in all the organs an 
excess of connective tissue, followed by fatty degeneration and 
the condition known as cirrhosis. The organs most frequently 
affected are the stomach, liver, and kidneys. Serious pathological 
alterations also occur in the cuTulatory, respiratory, and nervous 
systems. 

Alcohol is not necessary to persons in good health. Prob- 
ably most persons, regardless of their state of health, do better 
without it. Its habitual use in the form of strong liquors is 
to be unreservedly condemned. The lighter wines and malt 
liquors, if obtained pure, may be consumed in moderate quanti- 
ties without ill effects. Even in these forms, however, the use 
of alcohol should be discouraged or, perhaps, prohibited in the 
young. 

Neither in hot nor in cold climates is alcohol necessary to 
the preservation of health, and its moderate use even produces 
more injury than benefit. The Polar voyager and the East 
India merchant are alike better off without alcohol than with it. 

It has long been a prevalent belief that the use of alcohol 
enables persons to withstand fatigue better than where no alcohol 
is used. A large amount of concurrent testimony absolutely 
negatives this belief^ 

The predisposition to many diseases is greatly increased by 
the habitual use of alcohol. Sun-stroke, the acute infectious 
diseases, and many local organic affections attack, by preference, 
the intemperate. A recent collective investigation by the British 
Medical Association brought out the fact that croupous pneu- 
monia is vastly more fatal among the intemperate than among 
those who abstained from the use of alcoholic Hquors. 

A further investigation by Baer has shown that the average 
expectation of life among users and dealers in alcoholic liquors 
is very much shortened. The following table gives a compara- 
tive view of the expectation of life in those who abstained from 
and those who used alcohol: — 

»See Parkes' Hjgiene, 6tli ed., vol. i, pp. 315-327. 

8 



114 



TEXT-BOOK OF HYGIENE. 

Table XIY. 
expectation of life. 



Age. 


Abstainers. 


Alcohol Users. 


At 25 


32.08 3^ears. 
25.92 " 
19.92 " 
14.45 " 
9.62 " 


26.23 years. 
20.01 " 


"35 


"45 


15.19 " 


"55 


11.16 " 


"65 


8.04 " 



Table XV shows the mfluence of alcohol upon the mortality 
from various diseases : — 

Table XY. 





General Male Popu- 
lation (per cent.). 


Alcohol Venders 
(per cent.). 


Brain disease 

Tuberculosis 


11.77 
30.36 
9.63 
1.46 
1.40 
2.99 
2.49 
22.49 


14.43 

36.57 


Pneumonia and pleuritis .... 

Heart disease 

Kidney disease 

Suicide 

Cancer 


11.44 
3.29 
2.11 
4.02 
3.70 


Old age . 


7.05 



Alcohol as a beverage is consumed in the various forms of 
spirits, wines, and fermented liquors. The varieties of spirits 
most frequently used are brandy, whisky, rum, and gin. They 
are all procured by distillation. 

Brandy is distilled from fermented grape-juice, and has a 
characteristic aromatic flavor. When pure and mellowed with 
age it is the most grateful to the palate of all distilled spirits. 

Whisky is distilled from barley, rye, oats, corn, or potatoes. 
Each of these has a peculiar flavor, depending upon the par- 
ticular volatile ether formed during the distillation. Rye-, barley-, 
and corn- whiskies are almost exclusively used in this country. 



BEVERAGES COXTAIXIXG ALCOHOL. 115 

Rum is distilled from molasses, and is a favorite insfredient 
in hot punches. It is often used with milk, eggs, and sugar, in 
the preparation of eggnog, a higlily-nutritious, stimulatmg drink, 
which is often prescribed with great benefit in acute and chronic 
wasting: diseases. 

Gin is an ardent distilled spirit, flavored with oil of juniper. 
It has a widely-spread popular reputation as a cure for kidney 
diseases, but is probably oftener responsible for the production 
of these diseases than for their cure. 

All of the above-mentioned liquors contain from 40 to 60 
per cent, of alcohol, and should always be diluted before being 
taken into the stomach, in order to prevent the local irritant 
effects of the alcohol upon the gastric mucous membrane. 

AYine is the product of the alcoholic fermentation of the 
saccharine constituents of fruits. AVine is usually derived from 
the grape, though other fruits may also furnish it. The stronger 
wines (sherry, port, madeira) contain from 16 to 25 per cent. 
of alcohol. The lighter wines (hock, red and wdrite Bordeaux 
and Burgimdy wines, champagnes) contain from 6 to 15 per 
cent, of alcohol. Some also contain considerable free carbonic 
acid (sparkling wines), of wiiich the champagnes are types. The 
red and white Bordeaux and Ehine wines are probably the 
least objectionable of these beverages for habitual use. They 
contain sufficient alcohol to be lightly stimulant, have a pleasant 
acid flavor, and are least likely to produce the bad effects which 
usuallv follow in the wake of the habitual use of the stron^-er 
wmes or ardent spirits. 

Preference should be given to the wines of domestic manu- 
facture, on account of the great probabdity of adulteration of the 
favorite brands of foreign wines. Many of the California. Vir- 
ginia, Xew York, and Oliio wines compare very favorably in 
flavor with those imported from abroad. The more reasonable 
cost of these domestic wines is also a point in their favor. 

Cider is the fermented juice of apples. It frequently pro- 
duces unpleasant gastric and intestmal disturbances when dr'unk, 



116 TEXT-BOOK OF HYGIENE. 

on account of the large quantity of malic acid contained in it. 
Although it is usually ranked as a " temperance drink," it is 
quite capable of causing intoxication when consumed in large 
quantities. 

Beer is the fermented extract of barley, mixed with a 
decoction of hops and boiled. It should be prepared only of 
malt, hops, yeast, and water, and should contain from 3 to 
4 per cent, of alcohol, 5 to 6 per cent, of extract of malt 
and hops, 2 to 4 per cent, of lactic and acetic acids, and from 
\ to i per cent, of carbonic acid. This ideal is, how- 
ever, rarely attained in the article sold by the liquor dealer. 
Numerous adulterations are practiced on the unsuspecting con- 
sumer. The hops are frequently substituted by aloes, calamus, 
and ginger, or by the more deleterious picric acid or picrotoxin. 
The rich brown color, sweetness, body, and creamy foam are 
produced by caramel and glycerin. The more expensive barley- 
malt is substituted by starch and rice, or grape-sugar and 
molasses. 

Ale, porter, and brown-stout are merely varieties of beer — 
some containing more sugar, others more extractive matter. 

Beer and its correlatives have considerable dietetic value, 
owing not merely to the alcohol they contain, but largely to the 
sugar and acids entering into their composition. When used to 
excess they often cause a considerable accumulation of fat. 

Kumys is the national beverage of the nomadic tribes of 
Tartary. It consists of the milk of mares which has undergone 
fermentation, partly lactic and partly alcoholic in character. 
Recently it has been introduced into Europe and also into this 
country, where it is made of cows' milk. It is a palatable, 
nutritious stimulant, and is often very useful as a dietetic article 
in disease. 

Kefyr is a product of the fermentation of milk which bears 
some resemblance to kumys. The following table (Table XYI) 
gives a comparative view of the composition of true kumys, the 
same prepared from cows' milk, and kefyr : — 



ALKALOIDAL BEVERAGES. 



117 



Table XYI. 





True Kumys 
(percent.). 


Cows' Milk Kumys 
(percent.). 


Kefyr 
(percent.). 


Proteids 

Fats 

Sugar 

Lactic acid 

Alcohol 

CO2 . . . 


2.20 
2.12 
1.53 
0.90 
1.72 
0.85 


2.35 

2.0t 
1.81 
0.40 
1.90 
0.80 


3.12 
1.95 
1.62 

0.83 
2.10 
0.92 



THE ALKALOIDAL BEVERAGES. 

The virtues of the alkaloidal beverages depend upon certain 
alkaloids which differ very little in their chemical composition 
or physiological effects, and upon certain volatile aromatic con- 
stituents of the various articles used. The principal articles 
employed in the preparation of these beverages are coffee, tea, 
chocolate, mate, and coca. It is estimated that 500,000,000 
people drink coffee, 100,000,000 tea, 50,000,000 chocolate, 
15,000,000 mate or Paraguay tea, and 10,000,000 coca. All 
of these are active nervous stimulants and retarders of tissue- 
waste. They are all liable to produce serious functional dis- 
turbances of the nervous, digestive, and circulatory systems if 
used to excess. Anaemia, digestive derangements, constipation, 
pale, sallow complexion, loss of appetite, disturbed sleep, nervous 
headaches and neuralgias are the most marked of these effects. 

On the other hand, when taken in moderate quantity, the 
alkaloidal beverages enable the consumer to withstand cold, 
fatigue, and hunger; they promptly remove the sensation of 
hunger, and diffuse a glow of exhilaration throughout the body. 

Coffee. — Coffee is the ripe fruit (seed) of the Caffea Arahica^ 
a native of Arabia and Eastern Africa, but now cultivated in 
other tropical regions of the world. The fruit consists of two 
flat-convex beans, the flat surfaces of which are apposed to each 
other. These are enclosed in a fibrous envelope which is some- 
times used as a cheap substitute for the coffee-bean. 

The beverage, coffee, is an infusion of the roasted and 



118 TEXT-BOOK OF HYGIENE. 

ground bean in hot water. Its virtues depend upon the alkaloid, 
caifein, and an aromatic oil. The latter, being volatile, is driven 
off by long-continued heat. Hence boiled coifee lacks the 
grateful aroma of that which is made by simply infusing the 
ground bean in hot water. 

The great demand for coffee and its comparatively high 
price have caused it to be extensively adulterated and substituted 
by other natural and artificial products. Artificial coffee-beans 
have been made of clay, dough, or extract of chicory, colored 
to imitate the natural bean. The fraud is easily detected by 
placing the beans in water, when the artificial product soon falls 
to pieces, while the natural beans undergo no change of shape 
or consistence. 

Ground coffee as found in the stores is usually adulterated. 
The materials used for sophistication are : The grounds of coffee 
previously used, the roasted root of chicory, acorns, rye or barley, 
carrots, sunflower-seeds, caramel, and a number of articles of 
similar value, generally harmless. 

Tea, — The plants which furnish the tea-leaves are natives 
of China, Indo-China, and Japan. The tea-leaves contain a 
crystalline alkaloid, thein, identical in composition and proper- 
ties with caffein. The various sorts of tea found in the market 
(green and black teas, etc.) differ only in the relative proportion 
of tannin and thein contained in each. The aromatic principle 
also varies somewhat in the different sorts. 

Tea is adulterated to quite as great an extent as coffee, the 
leaves of various plants bearing more or less resemblance to tea- 
leaves being added to the latter. Much of the tea found in the 
market is colored artificially with Prussian blue and iron oxide. 
These additions are harmless, as they are not soluble in water. 

Chocolate. — Cocoa, from which chocolate is derived, is 
widely different in composition from tea and coffee. In addi- 
tion to its active principle, theobromin, which is identical with 
caffein and thein, it contains nearly 50 per cent, of fat, which 
renders it an article of high nutritive value. 



TOBACCO. 119 

Mate, or Paraguay tea, guarana, and coca are used to a 
considerable extent in some parts of South America as substi- 
tutes for coffee and tea. Their composition is not well known, 
but their effects are believed to depend upon alkaloidal princi- 
ples similar to caffein and thein. 

TOBACCO. 

Closely connected with the subjects treated in this chapter 
are the effects of the constant use of tobacco upon the human 
system The depressing effects of tobacco, due principally to 
the nicotine upon the nervous and digestive systems, have long 
been recognized. Recently, however, it has been found that 
very serious symptoms are produced upon the sense of vision by 
the constant or excessive use of tobacco. A special form of 
amaurosis, termed tobacco amaurosis, has been frequently noticed 
since attention was first called to it by Mackenzie. 

[The following additional works are recommended to the 
student : — 

Thos. K. Chambers, on Diet in Health and Disease. — Edward Smith, 
on Foods. — Forster, Ernahrung, in Pettenkofer u. Ziemssen's Handbuch 
der Hygiene. — Munk und Uffelmann, Die Ernahrung des Gesunden und 
Kranken Menschen.] 



CHAPTER IV. 



Soil. 



Hippocrates treated at length, in one of his works, of the 
sanitary mfluences of the soiL Others of the older writers, 
especially Herodotus and Galen, called attention to the same 
subject, and Yitruvius, the celebrated Eoman architect, who 
flourished about the beginning of the Christian era, taught that 
a point of first importance in building a dwelling was to select a 
site upon a healthy soil. 

From this time until the beofinnino^ of the ei£:hteenth cen- 
tury, yery Httle of value is found in medical Hterature bearing 
upon this subject. In 171 T, howeyer, Lancisi published his 
great work on the causes of malarial fevers, in which he laid 
the foundation for the modem theory of malaria, and pointed 
out the relations existino^ between marshes and low-lvinsr lands 
and those diseases by common consent called malarial. Other 
authors of the eighteenth and the early part of the nineteenth 
centuries refer to the connection between the soil and disease, 
but exact investigations have only been made within the last 
thirty years. 

When it is considered that the air that human beings 
breathe, and much of the water they drink, are influenced hi 
their composition by the matters in the soil, the great importance 
of possessing a thorough knowledge of the physical and chemical 
conditions of the soil becomes evident to every one. 

PHYSICAL AND CHEMICAL CHARACTERS OF THE SOIL. 

In the hygienic, as in the geological sense, rock, sand, clay, 
and gravel are included in the consideration of soils. 

The soil, as it is presented to us at the surface of the earth, 

(121) 



122 TEXT-BOOK OF HYGIENE. 

is the result of long ages of disintegration of the primitive 
rocks by the action of the elements, of the decomposition of 
organic remains, and, possibly, of accretions of cosmical dust. 
The principal factor, however, is the action of water upon rock, 
in leveling the projections of the earth's surface produced by 
volcanic action. 

Soils vary considerably in physical and chemical constitu- 
tion. A soil may, for example, consist exclusively of sand, of 
clay, or of disintegrated calcareous matter. Other soils may 
consist of a mixture of two or more of these, together with 
vegetable matter undergoing slow oxidation. In forests, a layer 
of this slowly-decomposing vegetable matter of varying thick- 
ness is found, covering the earthy substratum. This organic 
layer is called liumus^ and when turned under by plough or 
spade, and mixed with the sand or clay base, it constitutes the 
ordinary agricultural soil. 

THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 

The interstices of the soil are occupied by air or water, or 
by both together. The soil's atmosphere is continuous with, 
and resembles in physical and chemical properties, that which 
envelops the earth. Its proportion to the mass of the soil 
depends upon the degree of porosity of the soil, and upon the 
amount of moisture present. In a very porous soil, such as, for 
example, a coarse sand, gravelly loam, or coarse-grained sand- 
stone, the amount of air is much greater than in a clayey soil, 
granite, or marble. So, likewise, when the soil contains a large 
proportion of water, the air is to this extent excluded. The 
porosity of the various soils, as evidenced by the amount of air 
contained in them, is much greater than would, at first thought, 
be supposed. Thus it has been found that porous sandstone 
may contain as much as one-third of its bulk of air, while the 
proportion of air contained in sand, gravel, or loose soil may 
amount to from 30 to 50 per cent. 

The ground-air is simply the atmospheric air which has 



THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 123 

penetrated into the interstices of the soil and taken part in the 
various chemical decompositions going on there. In consequence 
of these chemical changes the relative proportions of the oxygen 
and carbonic acid in the air are changed — oxygen disappearing 
and giving place to carbon dioxide. It is well known that 
during the decay of vegetable matter in the air carbon dioxide 
is formed; one constituent of this compound, the carbon, being 
derived from the vegetable matter, while the oxygen is taken 
from the air. Hence, if this action takes place where there is 
not a very free circulation of air, as in the soil, the air there 
present soon loses its normal proportion of oxygen, which enters 
into combination with the carbon of the vegetable matter to 
form carbon dioxide. 

Thirty years ago, MM. Boussingault and Levy, two dis- 
tinguished French chemists, examined the air contained in 
ordinary agricultural soil, and found that the oxygen w^as 
diminished to about one-half of the proportion normally present 
in atmospheric air, while the carbon dioxide was enormously 
increased. The exact results obtained by Boussingault and 
Levy were as follow: — 

In 100 volumes of ground-air there were 10.35 volumes 
of oxygen, 79.91 volumes of nitrogen, 9.74 volumes of carbon 
dioxide. In atmospheric air, on the other hand, there are in 
100 volumes 20.9 volumes of oxygen, 79.1 volumes of nitrogen, 
0.04 volume, or about gV ^^ 1 P^i' ^^^t- ^^ carbon dioxide. 

In spite of the striking results obtained by these two 
chemists, very little attention was paid to them by sanitarians, as 
very few seemed to have any clear notion of the relations exist- 
ing between the motions of the air above-ground and that under- 
ground. 

In 1871, however. Professor von Pettenkofer, of Munich, 
published the results of his own examinations into the constitu- 
tion and physical conditions of the ground-air, and the relations 
of the latter to the propagation of epidemic diseases. These re- 
searches, which created a wide-spread interest in the subject, 



124 TEXT-BOOK OF HYGIENE. 

were extended by other observers in all parts of the world. 
These observers, prominent among whom were Professors Fleck, 
Fodor, and Soyka, in Germany ; Drs. Lewis and Cunningham, 
in India ; Prof. William Ripley Nichols, in Boston ; and Sur- 
geons J. H. Kidder and S. H. Griffith, of the U. S. Navy, in 
Washington, demonstrated that the increase of carbon dioxide 
in the ground-air is due to increased vegetable decomposition 
and to lessened permeability of the soil. A permeable, that is 
to say, a sandy or gravelly soil is likely to contain less carbon 
dioxide in its atmosphere than a dense, less permeable clay, 
although the amount of decomposition going on and the pro- 
duction of carbon dioxide in the former may considerably ex- 
ceed the latter. In the loose, sandy soil the circulation of the 
air is less obstructed, and the carbon dioxide may easily escape 
and be diffused in the superincumbent air, while the close-pored 
clay imprisons the carbon dioxide and prevents or retards its 
escape into the air above. 

The disappearance of oxygen from the ground-atmosphere 
is coincident with the production of an equivalent amount of 
carbon dioxide. It appears from this that in the soil an ox- 
idation of carbonaceous substances takes place, the product of 
which is found in the excess of carbon dioxide in the ground-air. 

Professor Nichols has found the proportion of carbon di- 
oxide in the air taken from a depth of 3 metres below the 
surface in the "made-land" of Boston to amount to 21.21 per 
thousand, the observation having been made in August. In 
December, at a depth of 2 metres, the proportion was 3.23 per 
thousand. Fodor, in Buda-Pesth, found the proportion of carbon 
dioxide to be 107.5 per thousand (over 10 per cent.), the air 
having been taken from a depth of 3 metres. 

The ground-air also teems with micro-organisms of various 
kinds, these being occasionally pathogenic. While in the great 
majority of instances the micro-organisms found are ordinary 
mold or fermentation fungi and bacteria of decay and putrefac- 
tion, disease-producing bacilli have also been observed in a 



THE ATMOSPHERE OF THE SOIL, OR GROUXD-AIR. 125 

number of instances. Among the latter are the bacillus of 
tetanus (Nicolaier), of anthrax (Frank), of malaria (Klebs and 
Tommasi-Crudeli),^ of malignant oedema (Koch and GaiFky), 
and of typhoid fever (Tryde). 

It may not be inappropriate to refer here to the claim of 
Professor Domingos Freire, of Brazil, to the discovery of the 
germ of yellow fever in the soil of a burial ground near Rio 
Janeiro. The exhaustive investigations of Dr. G. M. Sternberg, 
of the U. S. Army, under the direction of the government, have 
disposed eiFectuaUy of the claims and pretensions of the Brazilian 
scientist, and established the fact that Freire's organism has no 
pathological significance whatever, — at all events, that it has no 
relation to yellow fever. 

Cholera baciUi have not been found in the soil, but C. 
Frankel has shown experimentally that they can grow and 
multiply in the soil at various depths. At a depth of H 
metres their development was constant and progressive 
throughout the year. 

When the soil is dry, these organisms may be carried hither 
and thither in the movements of the ground-air, and thus infect 
the air of contiguous localities, or be transported to a distance. 

Movements of the ground-atmosphere are principally due 
to differences of pressure and temperature in the air above- 
ground. Owing to such differences the air from the soil fre- 
quently permeates houses, entering from cellars or basements. 
In winter, when the air of houses is very much more heated 
(and consequently less dense) than the air out-of-doors, 
the difference of pressure thus caused draws the ground-air up 
through the house, while the cold, external atmosphere pene- 
trates the soil and occupies the place of the displaced ground- 
air.^ A similar effect occurs in consequence of heavy rains. 

* While the pathogenic significance of Klebs' bacillus malarice is not generally accepted, 
it is thought proper, for the sake of completeness, to include it among the organisms sometimes 
found in the soil, 

' It is, of course, not strictly correct to say that the air is dramn up through the house 
by the diminution of pressure; it being rather forced out of the soil by the colder and denser 
outside air ; but the phrase is suflBciently exact and will be readily understood. 



126 TEXT-BOOK OF HYGIENE. 

The water fills up the interstices of the soil near the surface, and 
forces the ground-air out at points where the pores remain open. 
These places are the dry ground under buildings, where the air 
escapes and passes through floors and ceilings into the house 
above. Heavy rains may thus be the cause of pollution of the 
air in houses. The greater the porosity of the soil, the more 
likely is this to happen. This pollution of the house-air may 
be prevented by having impervious floors and walls to cellars 
and basements, or by interposing a layer of charcoal between 
the ground and the floor of the house. The latter does iK)t 
prevent the passage of the ground-air, but the charcoal layer 
absorbs or arrests the noxious matters, — filters the ground-air, 
as it were. 

In the spring and early summer the ground being colder 
than the air above it, and the ground-air consequently heavier 
and denser, the latter is not easily displaced. It is, perhaps, 
due to this fact that those infectious diseases which are proba- 
bly dependent upon the movements of the ground-air are less 
prevalent in the spring and early summer than in the latter 
part of the summer, autumn, and early winter. In the autumn 
the ground-air being warmer than the air above ground is easily 
displaced by the latter and forced out into the streets and houses 
to be inspired by men and animals. The same conditions may 
explain the greater likelihood of infection at night, which is 
proven for such diseases as malarial and yellow fevers. The 
colder outside air penetrates the interstices of the soil and forces 
out the impure ground-air. 

The researches of Fodor have demonstrated that the pro- 
portion of carbon dioxide in the ground-air may be taken as an 
approximative measure of the impurity of the soil whence the 
air is taken. The influence of the permeability of the soil, as 
before pointed out, must, however, not be overlooked in esti- 
mating the signification of the carbon dioxide. Fodor has 
shown that the proportion of carbon dioxide in the ground-air, 
and consequently the amount of organic decomposition, is 



THE ATMOSPHERE OF THE SOIL, OR GROUND-AIR. 127 

greatest in July and least in March. That the carbon dioxide 
is derived from the decomposition of vegetable matter has been 
proven by Pettenkofer. This observer examined specimens of 
air brought from the Lybian desert, and found that the propor- 
tion of carbon dioxide in the ground-air was exactly the same 
as in the air collected above-ground. There being no vegetable 
growth in the desert there can, of course, be no vegetable 
decomposition going on in the soil. 

The excess of carbon dioxide in the ground-air is an indi- 
cation of the deficiency of oxygen, as has been shown. The 
air at a depth of 4 metres below the surface was found to 
contain only from 7 to 10 per cent, of oxygen — one-half to one- 
third of the normal proportion. Many basements occupied by 
people as living-rooms extend from 1 to 3 metres under-ground, 
and hence are liable to be supplied with an atmosphere approach- 
ing in impurity that just mentioned. It requires no very vivid 
imagination to appreciate the dangers to health that lurk in such 
habitations. 

THE WATER OF THE SOIL, OR GROUND-WATER. 

At a variable depth below the surface of the ground, a 
stratum of earth or rock is found through which water passes 
with difficulty, if at all. Above this there is a stratum of water 
which moves from a higher to a lower level, and which varies 
in depth at different times according to the amount of precipita- 
tion (rain- or snow- fall), and according to the level of the nearest 
body of water toward which it flows. This stratum of water 
is termed the g round- ic at ei% and has within the last few years 
assumed considerable importance from its apparently close rela- 
tions to the spread of certain of the infectious diseases. The 
direction of horizontal flow of ground-water is always toward 
the drainage-area of the district. Thus, it is usually toward 
lakes, rivers, or the sea. Eains, or a rise in the river, cause a 
rise in the ground-water, while long-continued dry weather, or 
a low stage of the river which drains off the ground-water, 



128 TEXT-BOOK OF HYGIENE. 

causes a fall in the latter. On the sea-coast the ground-water 
oscillations probably correspond with the tides. The writer is 
not aware of any observations made to determine this point, 
with the exception of a single instance mentioned by Dr. De 
Chaumont. In Munich, where the ground- water flows toward 
the river Isar, which divides the city, it has been found that the 
annual range or oscillation (the difference between the highest 
and lowest level during the year) is 3 metres, while the hori- 
zontal movement amounts to 5 metres per day. In Buda-Pesth 
the annual range was found by Fodor to be less than 1 metre, 
while in some portions of India it ampunts to more than 12 
metres. As it is from the ground- water that the greater portion 
of the supply of drinking-water in the country and in villages 
and small towns is drawn, it becomes at once manifest how 
important it is to prevent, as far as possible, pollution of this 
source. Cess-pools and manure-heaps and pits, of necessity, 
contaminate the soil and also ground-water for a distance below 
and around them, and such water is clearly unfit for drinking 
and other domestic purposes. Hence, the reason why wells 
should not be placed too near privies and manure-heaps or pits 
becomes apparent. 

Between the level of the ground-water, or that portion of 
the soil where its pores are entirely occupied by the water — 
where, in other words, the ground is saturated — and the surface, 
is a stratum of earth more or less moist ; that is to say, the 
interstices of the soil are partly filled with water and partly with 
air. It is in this stratum that the processes of organic decay or 
putrefaction are most rapidly going on, in consequence of which 
the pollution of the ground-air occurs. The oxidation of non- 
nitrogenous matter in the soil results in the formation of carbon 
dioxide. On the other hand, nitrogenized compounds are 
oxidized into nitric acid and nitrates. When, however, putre- 
faction occurs, nitrous acid, or nitrites and ammonia, are formed, 
the oxidation not proceeding far enough to result in nitric acid. 

Recent observations seem to show that these processes of 



THE TTATER OF THE SOIL, OR GROUXD-WATER. 129 

decomposition are initiated and kept up by minute organisms 
termed bacteria, just as fermentation in liquids containing sugar 
can only take place in the presence of the yeast-plant. It has 
been found that when non-putrefactive decomposition goes on, 
there are always present multitudes of one variety of these 
minute organisms; while if putrefactive decomposition is going 
on, a number of other varieties of these organisms are present. 
Just as, when a fermenting liquid becomes putrid, the yeast-plant 
disappears and its place is taken by the ordinary bacteria of putre- 
faction, so in the soil, if the access of oxygen, which is necessary 
to the life of the bacteria of decay, is prevented, these organisms 
die and are succeeded by the organisms of putrefaction. It has 
been found that in a soil saturated with water the bacteria of decay 
cannot Hve, while those of putrefaction may flourish, because 
these latter organisms can sustain hfe and develop in the 
absence of oxvo-en. Professor Fodor's researches indicate that 
the most prominent organism of non-putrefactive decomposition 
or decay is that which is termed by Cohn bacterium Uneola; and 
that the bacterium termo is the principal organism of putrefaction. 

DISEASES SPREAD BY SOIL IMPURITIES. 

Given now an area of soil, say the ground upon which a 
house or city is built, with a moist stratum in which the pro- 
cesses of decay are active, and imagine a rise in the ground- 
water. The ground-air, charged with carbon dioxide and other 
products of decomposition, is forced out of the pores of the soil 
by the rising ground- water, and escapes into the external air, 
or through cellars and basements into houses, and may there 
produce disease. But the saturation of the soil with water pre- 
vents the further development of the bacteria of decay, and this is 
checked, or putrefaction may take place. If now the ground- 
water sinks to its former level or below, the processes of decay 
again become very active in the moist stratum, and large quan- 
tities of carbon dioxide and other inorganic compounds are 
produced. If the germs of infectious or contagious diseases 



130 TEXT-BOOK OF HYGIENE. 

have been introduced into the soil, they also multiply and may 
escape with the movements of the ground-air into the external 
atmosphere, and there produce their infective action. This, it is 
held by Pettenkofer and his followers, is what actually occurs in 
cholera and typhoid fever. Professor DeChaumont has laid 
down the rule that a soil with a persistently low stage of ground- 
water, say 5 metres below the surface of the ground, is healthy ; 
a persistently high stage of ground- water, less than 1^ metres 
below the surface, is unhealthy; while a fluctuating level of the 
ground-water, especially if the changes are sudden and violent, 
is very unhealthy. This would lead us to expect that places 
where this fluctuation is very great would show a large mortality 
from sucli diseases as are attributed to impurities in the soil. 
And this we And especially true in India. In certain localities 
in India, cholera, for example, is endemic ; that is to say, the 
disease is never entirely absent in such localities. Calcutta is 
one of these places. The rainy season begins about the first of 
May and continues until the end of October. During the next 
six months there is very little rain. It is fair to assume that 
the ground-water rises during the rainy season and checks decay 
and the multiplication of the germs of the disease in the soil, 
and that these processes become more active as the dry season 
advances and the ground-water level falls. If we note the 
death-rate from cholera in Calcutta it will be found that it bears 
a distinct relation to the movement of the ground-water. The 
deaths from cholera begin to increase from October and reach 
their height in April. Dr. Macpherson, who has written a very 
elaborate history of Asiatic cholera, shows this relation very 
clearly. For twenty-six years the average rain-fall was 157 cen- 
timetres. From May to October 1 42 centimetres fell, while the 
remaining 15 centimetres fell from November to April. The 
average number of deaths from cholera annually was 4013. 
Of these, 1238 died in the rainy season, while 2775, nearly 
three-fourths, died during the period of dry weather. 

In the cholera epidemics of 1866 and 1873 in Buda-Pesth, 



DISEASES SPREAD BY SOIL IMPURITIES. 131 

the same relations existed between the ground- water and the 
cholera. As the level of the ground-water rose the cholera 
diminished, while the disease increased upon the sinking of the 
ground- water. Exactly the same behavior was exhibited by the 
disease in Munich in 1873. 

There seems good reason to believe that typhoid fever is 
propagated in consequence of movements of the ground-water, 
in the same way as above explained for cholera. This does not 
exclude the infection of drinking-water by the disease-germ, 
since much of the drinking-water used, as before stated, is drawn 
from the ground- water. Pettenkofer, Buhl, and Virchow have 
shown that the death-rate from typhoid fever has a distinct and 
definite relation to the ground-water oscillations. This has been 
inconte^ably proven for two cities, Munich and Berlin. When 
the level of the ground- water is above the average, typhoid fever 
decreases; when it is below the average, the number of cases 
becomes greater. Dr. H. B. Baker has demonstrated that the 
fluctuation of the ground-water level in the State of Michigan 
is similarly followed by a change in the morbility and mortality 
from typhoid fever.-^ Hence, it may be regarded as an established 
law that the rise and fall of the ground-water bears a definite 
relation to the morbility rate of typhoid fever. 

Nearly thirty years ago Dr. Henry I. Bowditch, of Boston, 
called attention to the frequent connection between cases of 
pulmonary consumption and dampness of the soil upon which 
the patients lived. After a very extended and laborious investi- 
gation Dr. Bowditch formulated these two propositions: — 

" First — A residence in or near a damp soil, whether that 
dampness be inherent in the soil itself or caused by percolation 
from adjacent ponds, rivers, meadows, or springy soils, is one of 
the principal causes of consumption in Massachusetts, probably 
in New England, and possibly other portions of the globe. 

" Second. — Consumption can be checked in its career, and 

* The Relation of fhe Depth of Water in Wells to the Causation of Typhoid Fever, 
Public Health, vol. x, p. 184-213. 



132 TEXT-BOOK OF HYGIENE. 

possibly — nay, probably — prevented in some instances by atten- 
tion to this law."^ 

Dr. Buchanan, of England, about the same time showed 
that the thorough drainage of certain English cities had mark- 
edly diminished the deaths from consumption in the drained 
cities. So far as the writer is aware, not a single fact has been 
established which militates against the law laid down by Dr. 
Bowditch, and so strongly supported by the statistical researches 
of Dr. Buchanan, yet hardly any notice has been taken of these 
results by physicians. Few know anything of them, and still 
fewer seem to have made practical use of such knowledge in 
advising patients. As corroborative of the views of Dr. Bow- 
ditch, the rarity of consumption in high and dry mountainous 
districts or plateaus may be cited. 

A recent study of the topographical distribution of con- 
sumption in the State of Pennsylvania, by Dr. William Pepper, 
apparently confirms Dr. Bowditch's conclusions in nearly every 
particular. It is now known that the direct cause of consump- 
tion is the bacillus tuberculosis, discovered by Dr. Pobert Koch. 
The relation between soil-moisture and the increase of consump- 
tion will probably be found in the more favorable conditions 
of development of the tubercle bacillus furnished by a moist 
medium. 

DISEASES OF ANIMALS PROBABLY DUE TO SIMILAR CONDITIONS OF 

THE SOIL. 

The modern study of the sanitary relations of the soil is 
still in its infancy. Whatever definite knowledge has been 
gained relates merely to physical or chemical conditions of the 
soil and its atmosphere and moisture, or possibly the relations 
of these to the spread of certain diseases in human beings. But 
there is, perhaps, a wider application that may be made of such 
knowledge than has been heretofore suggested. The domestic 
animals which form such a large portion of the wealth of this 

* Consumption in New England and Elsewhere, 2d ed., p. 87. Boston, 1866. 



i 



DISEASES OF ANIMALS DUE TO SIMILAR CONDITIONS OF SOIL. 133 

country — horses, cattle, sheep, and hogs — are hable to mfectious 
and contagious diseases, as well as are human beings, and many 
millions of dollars are lost annually by the ravages of such 
diseases. Now, from what is known of such diseases as splenic 
fever among cattle, and of the so-called swine plague, it does 
not appear improbable to the writer that the source of infection 
is a soil polluted by the poisonous germ of these diseases, just 
as it seems demonstrated that cholera and typhoid fever and 
possibly malarial fevers are so caused. The laborious investiga- 
tions of M. Pasteur in France have shown that the cause of 
splenic fever, when once introduced into a locality, will remain 
active for months, and even years, and it seems probable that a 
study of the soil in its relations to the diseases of domestic 
animals is a subject to which attention may profitably be 
given. 

It is well known that milch-cows frequently suffer from a 
disease identical in its nature with consumption in human 
beings. It is believed by many that the milk of such animals 
is not only unfit for food by reason of its poor quality, but that 
it may convey the disease to human beings when used as food. 
The observations of Bowditch and Buchanan, quoted above, 
show that consumption in man may be, and doubtless is, 
frequently caused by soil-wetness. It seems probable that the 
same cause should produce similar effects in the lower animals, 
and it is the writer's firm conviction that an examination into 
the circumstances under which cows become attacked by con- 
sumption would prove this probability a fact. 

DRAINAGE. 

In many soils drainage is necessary in order to secure a 
constant level of the ground-water at a sufficient depth below 
the surface. Drainage and sewerage must not be confounded 
with each other. Drainage contemplates only the removal of 
the ground-water, or the reduction of its level, while sewerage 
aims to remove the refuse from dwelhngs and manufactories, 



134 TEXT-BOOK OF HYGIENE. 

including excrementitious matters, waste-water, and other 
products, and in some cases the storm-water. 

Sewers should never be used as drains, although for 
economy's sake sewer- and drainage- pipes may be laid in the 
same trench. Sewer-pipe must be perfectly air-tight and water- 
tight to prevent escape of its liquid or gaseous contents into the 
surrounding soil and rendering it impure. Drainage-pipe, on 
the other hand, should be porous and admit water freely from 
without. Escape of the contents of the drain-pipe into the 
surrounding soil will not produce any pollution of the latter. 

The best material for drains is porous earthenware pipe, or 
the ordinary agricultural drain-tile. Coarse gravel or broken 
stones may also be used, and prove efficient if the drains are 
properly constructed. Referring again to the aphorism of 
Professor DeChaumont, that a persistently low ground-water, 
say 5 metres down, or more, is healthy; that a persistently high 
ground- water, less than 1| metres from the surface is unhealthy; 
and that a fluctuating level, especially if the changes are sudden 
and violent, is very unhealthy, the necessity appears obvious 
that in the construction of drainage-works the drains should be 
placed at a sufficient depth to secure a level of the ground- water 
consistent with health. This depth should never be less than 
3 metres, and, if possible, not less than 5 metres. Care must be 
taken that the outflow of the drain is unobstructed, in order 
that the soil may be kept properly dry at all times. 

In the absence of a proper mechanical system of drainage, 
the planting of certain trees may efficiently drain the soil. It 
has been found that the eucalyptus tree has produced drying of 
the soil when planted in sufficient numbers in marshy land. 
The roots absorb a prodigious quantity of water, which is then 
given off by evaporation from the leaves. Sunflower-plants have 
a similar effect upon wet soils. 



CHAPTER y. 

Removal of Sewage. 

In all lar2*er communities certain arrano^ements are neces- 
sary to secure a prompt and efficient removal of excreta and 
the refuse and used water of households and manufacturing 
establishments, the sweepings of streets, and rain-water. 

The total quantity of excrementitious products — faeces and 
urine — for each individual, including men, women, and children, 
has been estimated by Professor von Pettenkofer as 90 grammes 
of faecal and 1170 grammes of urinary discharge daily. This 
would give for a population of 1000 persons 34,000 kilogrammes 
of faeces and 428,000 litres of urine per year. If to this is 
added a minimum allowance of 159 litres of water per day to 
each individual, a complete sewerage system for a population 
of 1000 persons would require provision for the discharge of 
160,000 litres of scAvage passing through the sewers every day. 
In this estimate storm-water and such accessory feeders of the 
sewage are omitted. 

The organic matters contained in sewage, even if free from 
the specific germs of disease, give rise to noxious emanations, 
which, when inhaled, probably produce a gradual depravement 
of nutrition that renders the system an easier prey to disease. 
For this and other reasons it is important that such measures be 
adopted as will secure the removal of sewage matters from the 
immediate vicinage of houses as quickly as possible after they 
have been discharged. 

The impregnation of the soil with sewage produces a con- 
tamination of ground-air and ground-water, which may become 
a source of grave danger to health. By polluting the ground- 
water it eventually vitiates the well-water, which is nearly always 
derived from that source. 

(135) 



136 TEXT-BOOK OF HYGIENE. 

The system of removal of excrementitious matters which 
any community will adopt depends to a considerable extent upon 
financial considerations. Although the sanitarian must insist 
upon the pre-eminent importance of the cause of public health, 
his suggestions will receive little attention from municipal or 
state legislatures unless they can be carried out without involv- 
ing the community too deeply in debt. For this reason it is a 
matter of great practical importance that the student of sani- 
tary science should make himself familiar with the relative cost 
as well as with the hygienic significance of the various methods 
of sewage removal in use. 

The difierent systems in use for the removal of sewage 
matters may be considered in detail under the following five 
heads : — 

1. The common privy, or privy- vault systems. 

2. The Rochdale or pail system, and its modifications. 

3. The earth- or ash- closet system. 

4. The pneumatic system of Liernur. 

5. The water-carriage systems. 

1. Tlie Privy and Privy-well Systems. — While from a 
sanitary point of view privies of all kinds, whether w^ells or 
cess-pits, are to be unreservedly condemned, it is not likely that 
they will cease to be built for many years to come. It becomes 
necessary, therefore, to point out by what means the objections 
against them may be diminished, and their evil consequences in 
some measure averted. 

In the first place, a privy- vault should be perfectly water- 
tight in order to prevent pollution of the surrounding soil by 
transudation of the contained excremental matters. The walls 
should be of hard-burned brick laid in cement. The cavity 
should be small in order that the contents may be frequently re- 
moved, and not allowed to remain and putrefy for months or 
years. A water-tight hogshead sunk in the ground makes an 
economical privy-tank or receiver. A privy must not be dug in 
a cellar, or in too close proximity to the house-walls. Unless 



REMOVAL OF SEWAGE. 137 

these last precautions are taken the offensive gases from the 
mass of decomposing faecal matter in the privy will constantly 
ascend into and permeate the air of the house. 

All privies should be ventilated by a pipe passing from just 
under the privy-seat to a height of about a metre above the 
roof of the house. A gas-flame, kept burning in the upper portion 
of this pipe, will increase its ventilating power by creating a 
strong and constant upward current. 

Deodorization of the contents of privies may be secured in 
a measure by means of sulphate of iron, phenyle, carbolic acid, 
or diy earth. The first named is probably the most economical, 
most easily applied, and very effective. A solution containing 
from J to 1 kilogramme of the salt in 4 litres of water is poured 
into the privy as often as necessary to prevent offensive odors. 
This solution may be conveniently prepared by suspending a 
basket or bag containing about 25 kilogrammes of the sulphate 
in a barrel of water. In this way a saturated solution will be 
maintained until the salt has been entirely dissolved. Phenyle 
is likewise a good deodorizer as well as an excellent disinfectant. 

The most rigid deodorization by chemicals will, however, 
be less effective than thorough ventilation, for it must be re- 
membered that the mere destruction of an offensive odor is not 
equivalent to removing all the deleterious properties that may 
be present. It is not at all certain that those elements of sew- 
age which are the most offensive to the sense of smell are most 
detrimental to health. 

Privies should be emptied of their contents at stated inter- 
vals. A strict supervision should be exercised over them by the 
municipal authorities in cities and towns to prevent overflowing 
of their contents. 

In many places the method of removing the contents of 
privies is the primitive one with shovel, or dipper and bucket. 
In most cities and large towns, however, the privy- vaults or tanks 
are now emptied by means of one of the so-called odorless excavat- 
ing machines, of which there are a number of different patents. 



138 TEXT-BOOK OF HYGIENE. 

The process is rarely entirely odorless, however, as the careless- 
ness of the workmen frequently permits offensive gases to escape 
and pollute the air for a considerable distance. All the different 
forms of the apparatus act upon the pneumatic principle. One 
end of a large tube is carried into the cess-pool or vault to be 
emptied and the other attached to a pump, by means of which 
the material is pumped into a strong barrel-tank carried on 
wheels. At the top of the tank is a vent, over which is placed 
a small charcoal furnace to consume the foul gases escaping 
from the vent. 

In some cities and many of the smaller towns and villages 
in this country the primitive midden or pit system is still in use. 
A shallow pit is dug in the ground, over which is erected the 
privy. When the pit is full another is dug close by the side of 
it, and the earth from the new pit thrown upon the excrement 
in the old one. The privy is then moved over the new pit, and 
this is used until it too becomes full. The proceeding is re- 
peated as often as the pit becomes filled up with the excreta, 
until in the course of a few years all the available space in a 
yard has been honey-combed with the pits. Then the custom 
adopted in overcrowded cemeteries is followed, namely, the first 
pit is dug out again and the cycle is repeated. 

In other cities the privy- well system is largely in use. This 
is — next to the midden or shallow pit just described — the most 
pernicious system for the disposal of excreta that can be 
imagined. The wells are dug to such a depth as to reach the 
subterranean flow of water, in which the excremental matters 
are constantly carried off. Hence these receptacles never fill up, 
and never need cleaning. For this reason they are popular with 
property owners ; for, next to the primitive midden, they are the 
most economical of all the various methods adopted. The utter 
perniciousness of the system is, however, plain, because the soil 
for a considerable distance around each of these wells becomes 
a mass of putrid filth, contaminating the ground-water which 
feeds the drinking-water supplies m the vicinity ; polluting also 



REMOVAL OF SEWAGE. 139 

the ground-air, which eventually reaches the surface, or the in- 
terior of houses, when the pressure of the outside atmosphere 
diminishes or the ground-water level rises. It must, therefore, 
be evident that the best ventilating arrangements, or the most 
thorough and consistent disinfection, can have very little, if any, 
effect in removing the very grave objections to this baneful 
system. 

The pri^^Mvell system for the removal of excreta cannot be 
recommended for adoption by any sanitarian. 

2. The Rochdale^ or Pail-closet System. — The Rochdale 
system of removal of excreta has won the support of many dis- 
tinguished sanitarians on account of its simplicity, its economy, 
and its compliance with most sanitary requirements. The ex- 
creta, both solid and liquid, are received into a water-tight pail, 
either of wood or metal, and removed once or oftener a week, 
a clean and disinfected pail being substituted for the one 
removed. In Rochdale, Manchester, and Glasgow in Great 
Britain, in Heidelberg in Germany, and in other cities abroad, 
where this system has been introduced, it has worked satisfac- 
torily. In this country a modification of the pail system, known 
as the Eagle Sanitary Closet, has been introduced by a firm in 
Charleston, S. C. The receptacle consists of an enameled-iron 
reservoir, with a neck just large enough to fit under the seat of 
the privy, and a quantity of disinfectant solution is put into the 
receptacle to prevent putrefaction of the excreta. The recep- 
tacles are replaced by clean ones every week. 

Mr. James T. Gardner, Director of the New York State 
Sanitary Survey, says, in a special report on methods of sewerage 
applicable in small towns and villages, concerning the pail 
system^ : — 

''Rochdale is a city of some 70,000, and Manchester of 
between 400,000 and 500,000 inhabitants. The higher class 
of houses are allowed to have water-closets, but four-fifths of 
the people are obliged to have ' pail-closets ' in their yards built 

1 Second Annual Report of New York State Board of Health, pp. 322, 323. 



140 TEXT-BOOK OF HYGIENE. 

according to plans of the Health Department. Their essential 
features are : A flag-stone floor, raised a few inches above the 
level of the yard ; a hinged seat, with a metal rim underneath 
for directing urine into the pail, which stands on the flag directly 
beneath the seat ; a hinged front and back to the seat, so that 
the pail or tub may be easily taken out and the place cleaned ; 
and a 6-inch ventilating pipe from under the seat to above the 
roof. In Rochdale they use a wooden pail or tub made of half 
of a disused parafline cask, holding about 40 kilogrammes ; in 
Manchester the ' pail ' is of galvanized iron and holds 40 litres. 
Under the direction of the authorities, they are removed once a 
week in covered vans, which bring clean tubs to be put in the 
place of the full ones taken away. Each tub is covered with a 
close-fitting double lid before removal. The tubs are taken to a 
depot, where their contents are deodorized and prepared as 
manure by mixing with ashes and a small proportion of gypsum 
to fix the ammonia. Subsequently, street-sweepings and the 
refuse of slaughter-houses are added. At Manchester there is 
by the side of each closet a very simple ash-sifler, from which 
the ashes fall into the tub and help to deodorize its contents. 

" The manure at Rochdale sells for about four-fifths of the 
cost of the collection and preparation. 

" In 1873 the net cost to the town of removing and dispos- 
ing of the house dry refuse and excrement was only about $95 
per annum per 1000 of population, — less than 10 cents a person 
per annum. 

" The system has been in operation more than twelve years. 

" The tubs are removed in the day-time without offensive 
odor. 

" Where ashes are frequently thrown into the tubs at Man- 
chester, very little odor is to be perceived in the closets. 

" For the villages of the State, which can have no general 
water-supply, I would unhesitatingly advise the use of the 
' pail ' or tub system as practiced in Manchester, England, as 
being, from a sanitary point of view, an immense improvement 



REMOVAL OF SEWAGE. 141 

over the death-breeding prlvy'VauIts m common use. The 
cheapness of the plan and the smallness of the original ontlay 
of brains and money, in comparison with that needed to build 
a good sewer system, will make it possible to introduce a tub- 
privy system into most villages half a century before sewers 
would meet with any consideration. 

" At a small cost the existing priv}- vaults can be cleaned 
and filled, and the privies altered into healthful tub-closets. The 
town authorities must then arrange for the removal of the tubs 
once a week, and for their thorough cleansing and disinfecting. 
Any isolated house, or group of houses, can use the tub system, 
taking care of it themselves. If the plan is adopted in villages 
it will doubtless spread into the country, and become the most 
powerful means of abolishing the fatal privy-vaults which are 
poisoning the farm- wells." 

3. EartJi' and Ash- Closets. — The earth- and ash- closets 
are devices in use to a large extent in England, and to a less 
degree in this country, for the purpose of rendering human ex- 
creta inodorous by covering them immediately after they are 
voided with dry earth or ashes. The earth-closet is the inven- 
tion of the Rev. Henry Moule, of England, and consists of an 
ordinary commode or closet, the essential feature of which is a 
reservoir containing dried earth or ashes, a quantity of which, 
amounting to about twice the quantity of faeces voided, is thrown 
upon the evacuation either by hand or by means of an auto- 
matic apparatus called a "chucker." Just as in the ordinary 
water-closet, by raising a handle a supply of water is thrown 
into the hopper to wash down the fseces into the soil-pipe, so, in 
the usual form of the earth-closet, raising the handle projects a 
quantity of earth upon the evacuated faeces and urine. By this 
means the excreta are rendered entirely inodorous and dry. 
The contents of the closets may be collected into a heap in a 
dry place. In the course of a few months the organic constit- 
uents have become oxidized, and the earth may be used over 
again for a number of times. A well-known sanitarian states 



142 



TEXT-BOOK OF HYGIENE. 



tliat he has used sifted anthracite coal-ashes ten or twelve times 
over in the course of three years. During this time the material 
under no circumstances gave any indication that it was " any- 
thing but ashes, with a slight admixture of garden soil."^ 

Dr. Buchanan, of England, comparing the advantages of 
the earth-closet with those of the water-closet, says : " It is 
cheaper in original cost ; it requires less repairs ; it is not in- 
jured by frost ; it is not damaged by improper substances being 





Fig. 4. — Pull-up Handle Commode, 
showing the door open for remov- 
ING Pail. The Flap of the Seat 
AND Earth-Reservoir are also Par- 
tially Raised to show the Con- 
struction. 



Fig. 5.— Showing the Apparatus 
Mounted on Bearers as when 
Fixed. Seat Removed, showing Me- 
chanical Arrangement. 



thrown down it ; and it very greatly reduces the quantity of 
water required by each household."^ 

In cities and towns the removal of the excreta should be 
carried out by or under the immediate direction of the mu- 
nicipal sanitary authorities. If this is neglected, abuses are 
liable to creep in which will vitiate the performance of any 
system, however faultless, if properly managed. 

Many advocates of the pail, dry earth, or privy systems urge 
the advantage of the large quantity of valuable manure which 

» The Sanitary Drainage of Houses and Towns, Waring, p. 250. 2d ed., 1881. 
3 Quoted in Waring, above cited, p. 264. 



REMOVAL OF SEWAGE. 143 

can be realized by converting: the excremental matters into pou- 
drette and other fertihzing compounds. Experience has shown, 
however, that the cost of preparing a satisfactory fertihzer from 
human excrement is much greater than can be reahzed from its 
sale. In all places in Great Britain and the continent of Europe 
where it has been tried the decision is against its practicability. 
The agricultural consideration should, however, be a secondary 
one. if the systems mentioned are economical and meet the 
sanitary requirements (which the privy system certainly does 
not). The adoption of one or other of them may be secured 
where more perfect but more complicated and expensive systems 
may be out of the question. 

4. The Pneumatic Sfjstem of Liernur. — A system w^hich 
seems to be useful in larger cities, especially where the topo- 
graphical conditions are such as to render necessary mechanical 
aid in overcoming obstacles to natural drainage, is the pneu- 
matic system devised by Captain Liernur, of Holland, and 
generally known as the Lieiiiur system. It consists of a set of 
soil-pipes running from the water-closets to central district 
reservoirs, from which the air is exhausted at stated internals. 
When a vacuum is created in the reservoir the contents of the 
water-closets and soil-pipes are driven forcibly into the reservoir 
by the pressure of air. The district reservoirs are connected by 
a separate system of pipes with a main depot, and the transfer 
of the faecal matter from the former to the latter is also accom- 
plished with the aid of pneumatic pressure. The complete 
system of Liernur provides that at the main depot the faecal 
matter shall be treated with chemicals, evaporated, and con- 
verted into a dry fertilizer — poudrette. It appears from the 
published reports that while the system has been partially 
adopted in three Dutch cities, in only one of them, Dortrecht, 
has the machinery for manufacturing poudrette been established. 
With reference to this Erismann^ says: "It seems never to have 

» Von Pettenkofer und Ziemssen. Handbuch der Hygiene. II Tli., 11 Abth, 1 Hlfte, 
p. 140. 



144 TEXT-BOOK OF HYGIENE. 

been in regular working order, for the fsecal masses are mixed 
with street-sweepings and ashes into a compost-mass, which 
causes no httle discomfort in the neighborhood by the offensive 
odors. In Amsterdam the faecal matters, which frequently do 
not find a ready sale, are partly made into a compost with 
sweepings, partly used to fertilize meadows, or simply discharged 
into the water." 

As to the practical working of the system the opinions 
differ widely. While the majority of sanitarians, including 
Virchow, von Pettenkofer, and Mr. Rawlinson, object to it as 
not fulfilling the demands of hygiene, the system has also been 
criticized by engineers as not being in accordance with the well- 
known principles of their science.^ 

Two other plans for the removal of faecal matter by pneu- 
matic pressure have been invented, namely, the Shone and the 
Berlier systems. Neither of these has been adopted to any 
considerable extent. Both seem to the author to fall far short 
even of the merits of the Liernur system. 

5. The Water- Carriage System of Sewerage. — Two sys- 
tems of removal of sewage by water-carriage are in use at the 
present time. They are technically known as the " combined " 
and the " separate " systems. In the former, which is the sys- 
tem upon which the most of the sewers in this country are 
constructed, all excreta, kitchen-slops, waste-water from baths 
and manufacturing establishments, as well as storm-water, are 
carried off in the same conduits. In the separate system, on 
the other hand, the removal of the storm-water is provided for, 
either by surface or under-ground drains, not connected with the 
sewers proper, in which only the discharge from water-closets 
and the refuse- water from houses and factories are conveyed. 
In the separate system the pipes are of such small calibre that 
a constant flow of their contents is maintained, preventing 

» Papers by Maj. C, H. Latrobe and Col. Geo, E. Waring, Jr., in Fifth Biennial Report 
Md. State Board of Health. See also, in favor of system, a paper by Dr. C. W. Chancellor, in 
same publication, and an elaborate description by the same author in Trans. Med. and Chir. 
Faculty of Md., 1883. 



REMOVAL OF SEWAGE. 145 

deposition of suspended matters and diminishing decomposition 
and the formation of sewer-gas. 

In the combined system, on the other hand, the sewers 
must be made large enough to receive the maximum rain-fall of 
the district. This requires a calibre greatly in excess of the 
ordinary needs of the sewer, and furnishes favorable conditions 
for the formation of sewer-gas and the development of minute 
vegetable organisms. The ordinary flow in a sewer of large 
calibre is usually so sluggish as to promote the deposition of 
solid matters and the gradual obstruction of the sewer. 

It is the opinion of the most advanced sanitarians that the 
separate system fulfills the demands of a rational system of 
sewerage better than any other at present in use. The objec- 
tions to the combined system are so many and so great that it 
does not seem advisable for sanitary authorities to recommend 
the construction of sewers on this principle in the future. 

The separate system of sewerage, indorsed as it is by high 
engineering and sanitary authorities, and by a satisfactory, prac- 
tical test of nine years in the city of Memphis and of six years 
in the town of Keene, N. H., seems to the author to possess 
merits above any other plan for the removal of excreta and 
house-wastes. The following description is from a paper by 
Col. George E. Waring, Jr. : '' A perfect system of sanitary 
sewerage would be something like the following: No sewer 
should be used of a smaller diameter than 6 inches (15 centi- 
metres) : a, because it will not be safe to adopt a smaller size 
than 4-inch (10 centimetres) for house-drains, and the sewer 
must be large enough to surely remove whatever may be de- 
livered by these; &, because a smaller pipe than 6-inch would 
be less readily ventilated than is desirable; c, and because it is 
not necessary to adopt a smaller radius than 3 inches (5 centi- 
metres) to secure a cleansing of the channel by reasonably 
copious flushing. 

"No sewer should be more than 6 inches (15 centimetres) 
in diameter, until it and its branches have accumulated a 



146 TEXT-BOOK OF HYGIENE. 

sufficient flow at the hour of greatest use to fill this size half full, 
because the use of a larger size would be wasteful, and because 
when a sufficient ventilating capacity is secured, as it is in the 
use of a 6-inch pipe, the ventilation becomes less complete as 
the size increases, leaving a larger volume of contained air to 
be moved by the friction of the current, or by extraneous in- 
fluences, or to be acted upon by changes of temperature and 
of volume of flow within the sewer. 

"The size should be increased gradually, and only so 
rapidly as is made necessary by the filling of the sewer half 
full at the hour of greatest flow. 

" Every point of the sewer should, by the use of gaskets 
or otherwise, be protected against the least intrusion of cement, 
which, in spite of the greatest care, creates a roughness that is 
liable to accumulate obstructions. 

" The upper end of each branch sewer should be provided 
with a Field's flush-tank of sufficient capacity to secure the 
thorough daily cleansing of so much of the conduit as from its 
limited flow is liable to deposit solid matters by the way. 

" There should be sufficient man-holes, covered by open 
gratings, to admit air for ventilation. If the directions already 
given are adhered to, man-holes will not be necessary for cleans- 
ing. The use of the flush-tank will be a safeguard against 
deposit. With the system of ventilation about to be described, 
it will suffice to place the man-holes at intervals of not less than 
1000 feet (305 metres). 

" For the complete ventilation of the sewers it should be made 
compulsory for every householder to make his connection without 
a trap, and to continue his soil-pipe above the roof of his house. 
That is, every house connection should furnish an uninter- 
rupted ventilation-channel 4 inches (10 centimetres) in diameter 
throughout its entire length. This is directly the reverse of the 
system of connection that should be adopted in the case of 
storm- water and street- wash sewers. These are foul, and the 
volume of their contained air is too great to be thoroughly ven- 



REMOVAL OF SEWAGE. 147 

tilated by such appliances. Their atmosphere contains too much 
of the impure gases to make it prudent to discliarge it through 
house-drains and soil-pipes. With the system of small pipes 
now described, the flushing would be so constant and complete 
and the amount of ventilation furnished, as compared to volume 
of air to be changed, would be so great, that what is popularly 
known as ' sewer-gas ' would never exist in any part of the 
public drains. Even the gases produced in the traps and pipes 
of the house itself would be amply rectified, diluted, and removed 
by the constant movement of air through the latter. 

"All house connections with the sewers should be through 
inlets entering in the direction of the flow, and these inlets 
should be funnel-shaped so that their flow may be delivered at 
the bottom of the sewer, and so that they may withdraAv the air 
from its crown; that is, the vertical diameter of the inlet at its 
point of junction should be the same as the diameter of the 
sewer. 

"All changes of direction should be on gradual curves, and, 
as a matter of course, the fall from the head of each branch to 
the outlet should be continuous. Reduction of grade within 
this limit, if considerable, should always be gradual. 

" So far as circumstances will allow, the drains should be 
brought together, and they should finally discharge through one 
or a few main outlets. 

"The outlet, if water-locked, should have ample means for 
the admission of fresh air. If open, the mouth should be pro- 
tected aofainst the direct action of the wind. 

"It will be seen that the system of sewerage here described 
is radically different from the usual practice. It is cleaner, is 
much more completely ventilated, and is more exactly suited to 
the work to be performed. It ob^dates the filthy accumulation 
of street-manure in catch-basins and sewers, and it discharges all 
that is delivered to it at the point of ultimate outlet outside the 
town before decomposition can even begin. If the discharge is 
of domestic sewage only, its solid matter will be consumed by 



148 TEXT-BOOK OF HYGIENE. 

fishes if it is delivered into a water-course, and its dissolved 
material will be taken up by aquatic vegetation. 

"The limited quantity and the uniform volume of the 
sewage, together with the absence of dilution by rain-fall, will 
make its disposal by agricultural or chemical processes easy and 
reliable. 

"The cost of construction, as compared with that of the 
most restricted storm-water sewers, will be so small as to bring 
the improvement within the reach of the smaller communities. 

"In other words, while the system is the best for large 
cities, it is the only one that can be afforded in the case of 
small towns. 

" Circumstances are occasionally such as to require extensive 
engineering works for the removal of storm-water through very 
deep channels. Ordinarily, the removal of storm-water is a very 
simple matter, if we will accept the fact that it is best carried, 
so far as possible, by surface gutters, or, in certain cases, by 
special conduits, placed near the surface. 

" It is often necessary, in addition to the removal of house- 
waste, to provide for the drainage of the subsoil. This should 
not be effected by open joints in the sewers; because the same 
opening that admits soil-water may, in dry seasons and porous 
soils, permit the escape of sewage matters into the ground, 
which is always objectionable. 

" Soil-water drains may be laid in the same trench with the 
sewers, but preferably, unless they have an independent outlet, 
on a shelf at a higher level. When they discharge into the 
sewer they should always deliver into its upper part, or into a 
man-hole at a point above the flow-line of the sewage."^ 

The establishment of a system of sewerage presupposes a 
constant and abundant supply of water to keep all closets clean 
and all house-drains and street-sewers well flushed. Where this 
cannot be obtained, sewers would be likely to prove greater 
evils than benefits. In such cases one of the methods of removal 

» The Sewering and Drainage of Cities, Waring, Public Health, vol. v, p. 35. 



REMOVAL OF SEWAGE. 149 

of excreta before mentioned, either the pail- or earth- closet 
system, should be adopted. 

The final disposal of sewage is a problem that depends for 
its solution partly upon the agricultural needs of the country 
around the city to be sewered, partly upon the proximity of 
large bodies of water or running streams. When the city is 
situated upon or near large and swiftly-flowing streams, the 
sewage may be emptied directly into the stream without seriously 
impairing the purity of the latter, although the principle of thus 
disposing of sewage is wrong. Dilution, deposition, and oxida- 
tion Avill soon remove all appreciable traces of the sewage of 
even the largest cities. Where, on the other hand, the stream 
is inadequate in size to carry ofl" the sewage, or where, as in the 
Seine and Thames, the current is sluggish, some other method 
of final disposal must be adopted. 

In many cities of Great Britain and the continent of Europe 
the disposal of the sewage by irrigation of cultivated land has 
been practiced for a number of years. The reports upon the 
working of the system are generally favorable, although some 
sanitarians express doubts of the efiiciency of the system. In 
using sewage for the irrigation of land, two objects are secured : 
first, the fertilization of the land by the manurial constituents 
of the sewage, and, second, the purification of the liquid portion 
by filtration through the soil. The organic matters which have 
been held back by the soil undergo rapid oxidation in the presence 
of air and the bacteria of decay, and are converted into plant- 
food, or into harmless compounds. Sewage irrigation, as prac- 
ticed in Europe, must make provision for the disposal of a very 
large proportion of water in the sewage (street-wash, storm- 
water), which requires much larger areas of land than would be 
needed if only sewage material proper (water-closet and kitchen- 
waste) was to be thus disposed of In this country a practical 
experiment has recently been made at Pullman, Illinois, delivering 
only the sewage materials above mentioned upon the irrigation 
area. The success of the experiment is said to be satisfactory. 



150 TEXT-BOOK OF HYGIENE. 

All land used for sewage irrigation should be drained with 
drain- tile at a depth of 3 to 6 feet (1 to 2 metres) below the 
surface, in order to promote a rapid carrying off of the watery 
portion of the sewage, purified by filtration through the soil. A 
sandy loam is the best soil for irrigation. Clay is not sufficiently 
permeable to air and water, while pure sand allows the sewage 
to pass through too readily, before the organic matters in it 
have been sufficiently oxidized. It has been shown that the 
roots of plants assist largely in the oxidation of organic matter. 

The entire process of collecting and finally disposing of 
sewage matters, from the moment they are received in the house- 
receptacles until discharged into the swiftly-flowing stream or on 
the sewage farm, should be void of offense to the senses of sight 
or smell. With a proper construction and management of 
sewerage works, on the lines indicated in this chapter, it is 
believed these results can be attained. 

During the past two or three years a number of experi- 
ments have been made in this country with various processes for 
the disposal of excreta and garbage by cremation. In a general 
way the principle may be pronounced a success, although its 
proper application in practice is still under discussion. 

[The following works give fuller details upon the matters 
treated in the two foregoing chapters : — 

Erismann, Entfernmig der Abfallstoffe. Hdbcli. d. H^'giene, etc., 
II Til., I Abth., 1 Hlfte.— C. F. Folsom, Seventh Report Mass. State 
Board of Health, 1876, p. 276. — Sojdva, Stiidte-reiingung, in Realency- 
clopsedie d. ges. Heilk.,Bd. xiii, p. 14 et seq. — Pettenkofer, The Sanitary 
Relations of the Soil, in Pop. Sci. Monthly, vol. xx, p. 332, 468.— Rolie, 
Address on State Medicine, in Journ. Am. Med. Ass'n, July, 1887. — Cor- 
field and Parkes, The Treatment and Utilization of Sewage, 1887. — Re- 
ports of the Committee on Destruction of Garbage and Refuse, Public 
Health, vols, xiv and xv.] 



CHAPTER YI. 

Construction of Habitations. 



The importance of observing the principles of hygiene in 
the construction of habitations for human beings is not suffi- 
ciently appreciated by the public. Architects and builders them- 
selves have not kept pace with the sanitarian in the study of the 
conditions necessary to be observed in building a dwelling-house 
w^hicli shall answer the requirements of sanitary science. 

In an investigation conducted by Dr. Villerme^ it was found 
that in France, from 1821 to 1827, of the inhabitants of arron- 
dissements containing 7 per cent, of badly-constructed dwellings, 
1 person out of every 72 died ; of inhabitants of arrondissements 
contaming 22 per cent, of badly-constructed dwellings, 1 out of 
65 died ; while of the inhabitants of arrondissements containing 
38 per cent, of badly-constructed dwellings, 1 out of every 45 died. 

Inseparable from the question of the defective construction 
of dwellings is that of overcrowding in cities, because the most 
crowded portions of a city are at the same time those in which 
the construction of dwellings is most defective from a hygienic 
stand-point. The following tables show the relations of the 
death-rate to density of population in various large cities of 
Europe, and also the relations between overcrowding hi dwell- 
ings and the mortality from contagious diseases : — 

Table XYII. 
relation of death-rate to density of population. 



City. 


Mean Xnmber of Inhab- 
itants to each House, 


Average Death-rate per 
1000 Inhabitants. 


London 

Berlin 

Paris 

St. Petersburg 

"Vienna 


8 

32 
35 
52 
55 


24 
25 

28 
41 
47 







Q,uoted in Realencyclopsedia d. ges. Heilk, Bd. ii, 71. 



(151) 



152 TEXT-BOOK OF HYGIENE. 

In Glasgow, the death-rate in apartments with 1.31 occu- 
pants is 21.7 per 1000, while in apartments with 2.05 occupants 
the rate is 28.6 per 1000. 

In Buda-Pesth, in 1872-73, it was found that out of every 100 
deaths from all causes there were, from contagious diseases : — 

20 deaths in dwellings. with 1 to 2 persons in each room. 

OQ u a u u 3 '' 5 ^' '' <' ii 

32 " " " " 6 " 10 " " " " 

79 " " " " over 10 " " " " 

Dr. Jose A. de los Hios gives the following statistics, bear- 
ing upon the mortality of cholera, in relation to the number of 
persons occupying one room when attacked by it : — 

Of 10,000 persons attacked by cholera, and living 1 person 
to the room, 68 died. 

Of 10,000 persons attacked by cholera, from 1 to 2 to the 
room, 131 died. 

Of 10,000 persons attacked by cholera, living 2 to 4 to the 
room, 219 died. 

Of 10,000 persons attacked by cholera, living 4 or more to 
the room, 327 died. 

These figures show very clearly the vital importance of the 
application of sanitary laws in the construction and occupation 
of dwellings. 

Another curious and suggestive point is presented by some 
statistical researches on the mortality of Berlin, in regard to the 
death-rate among persons living in different stories of houses. It 
was found, for example, that the mortality in fourth-stoiy dwell- 
ings is higher than in the lower stories. Even basement dwell- 
ings furnish a lower death-rate. Still-births, especially, occur 
in a larger proportion among the occupants of the upper stories 
of houses. This may be explained by the unfavorable effects of 
frequent stair-climbing, especially in pregnant women. 

It is in the death-rate among young children that the effects 
of overcrowding and unsanitary construction of dwellings are 
especially manifest. The mortality returns from all the large 



CONSTRUCTION OF HABITATIONS. 



153 



cities of the world give mournful evidences of this every 
summer. 

The researches of Dr. H. I. Bowditch upon soil-wetness, to 
which reference has already been made in a previous chapter, 
show conclusively that persons living in houses situated upon 
or near land habitually or excessively wet, are especially prone 
to be attacked by pulmonary consumption. Dr. Buchanan ^ has 
corroborated the truth of Dr. Bowditch's observations by show- 
ing, from the records of a number of cities and towns of Great 
Britain, that, wdth the introduction of a good drainage system, 
bringing about a depression and uniformity of level of the 
ground-water, the mortality from consumption and other dis- 
eases very markedly diminished. The following table, showing 
the proportionate amount of this diminution, is abridged from 

the official reports" : — 

Table XYIII. 

results of sanitary work. 



Name of Place. 


Population 
in 1861. 


Average 

Mortality per 

1000 before 


Average 
Mortality 

per 1000 
since Com- 
pletion of 
Works. 


Saving of 
Life 


Reduc- 
tion of 

Typhoid 
Fever 

Rate (per 
cent. ) . 


Reduc- 
tion in 
Rate of 




Construction 
of Works. 


(percent.). 


Phthisis 
(percent.). 


Banbury . . 


10.238 


23.4 


20.5 


12i 


48 


41 


Cardiff . . . 


32.954 


33.2 


22.6 


32 


40 


17 


Croydon . . 


30,229 


23.7 


18.6 


22 


63 


17 


Dover . . . 


23,108 


22.6 


20.9 


7 


36 


20 


Ely ... . 


7,847 


23.9 


20.5 


14 


56 


47 


Leicester . . 


68,056 


26.4 


25.2 


H 


48 


33 


Macclesfield . 


27,475 


29.8 


23.7 


20 


48 


31 


Mertliyr . . 


53,778 


33.2 


26.2 


18 


60 


11 


Newport . . 


24,756 


31.8 


21.6 


82 


36 


32 


Rugby . . . 


7,818 


19.1 


18.6 


2i 


10 


43 


Salisbury . . 


9,030 


27.5 


21.9 


20 


75 


49 


Warwick . . 


10,570 


22.7 


21.0 


^ 


52 


19 



The following points must be taken into account in building 
a house in accordance with sanitary principles : — 

I. SITE. 

The building-site should be protected against violent 
winds, although a free circulation of air all around the house 

1 Ninth and Tenth Reports of the medical officer to the Privy Council. 

2 Sanitary Engineering, Baldwin Latham, p. 2. Chicago, 1877. 



154 TEXT-BOOK OF HYGIENE. 

must be secured. Close proximity to cemeteries, marshes, and 
injurious manufacturing establishments or industries must be 
avoided if possible. A requisite of the highest importance is 
the ability to command an abundant supply of pure water for 
drinking and other purposes. A neglect of this precaution will 
be sure to result to the serious inconvenience, if not detriment, 
of the occupants of the house. 

II. CHARACTER OF THE SOIL. 

The soil should be porous and free from decomposing ani- 
mal or vegetable remains, or excreta of man or animals. It 
should be freely permeable to air and water, and the highest 
level of the ground-water should never approach nearer than 
3 metres to the surface. The fluctuations of the ground-water 
level should be limited. In this connection, attention is again 
called to the aphorism of Dr. DeChaumont. ^ 

It is impossible to say positively that any kind of soil is 
either healthy or unhealthy, merely from a knowledge of its 
geological characters. The accidental modifying conditions 
above referred to, viz., organic impurities, moisture, the level 
and fluctuations of the ground-water, are of much greater 
importance than mere geological formation. The late Dr. 
Parkes, however, regarded the geological structure and conforma- 
tion as of no little importance, and summarized the sanitary 
relations of soils, variously constituted, as follows^: — 

"1. The Granitic, Met amoiyJnc, and Trap i^ocA;^.— Sites 
on these formations are usually healthy; the slope is great, water 
runs ofl* readily; the air is comparatively dry; vegetation is not 
excessive; marshes and malaria are comparatively infrequent; 
and few impurities pass into the drinking-water. 

"When these rocks have been weatliered and disintegrated 
they are supposed to be unhealthy. Such soil is absorbent of 
water; and the disintegrated granite of Hong Kong is said to 

* Chapter iv, p 130. 

a Practical Hygiene, 6th ed., vol. i, p. 359. 



CHARACTER OF THE SOIL. 155 

be rapidly permeated by a fungus; but evidence as to the effect 
of disintegrated granite or trap is really wanting. 

"In Brazil the syenite becomes coated with a dark sub- 
stance and looks like plumbago, and the Indians believe this 
gives rise to 'calentura,' or fevers. The dark granitoid, or 
metamorphic trap, or hornblendi<3 rocks in Mysore, are also said 
to cause periodic fevers; and iron hornblende, especially, was 
affirmed by Dr. Heyne, of Madras, to be dangerous in this 
respect. But the observations of Richter on similar rocks in 
Saxony, and the fact that stations on the lower spurs of the 
Himalayas on such rocks are quite healthy, negative Heyne's 
opinion. 

" 2. The Clay Slate. — These rocks precisely resemble the 
granite and granitoid formations in their effect on health. They 
have usually much slope, are very impermeable, vegetation is 
scanty, and nothing is added to air or drinking-water. 

"They are consequently healthy. Water, however, is 
often scarce, and as to the granite districts, there are swollen 
brooks during rain, and dry water-courses at other times swelling 
rapidly after rains. 

"3. The Limestone and Magnesian Limestone Rocks. — 
These so far resemble the former that there is a good deal of 
slope and rapid passing off of water. Marshes, however, are 
more common, and may exist at great heights. In that case, 
the marsh is probably fed with water from some of the large 
cavities which in the course of ages become hollowed out in the 
limestone rocks by the carbonic acid in the rain, and form 
reservoirs of water. 

"The drinking-water is hard, sparkling, and clear. Of 
the various kinds of limestone, the hard oolite is best and 
magnesian is worst; and it is desirable not to put stations on 
magnesian limestone if it can be avoided. 

" 4. The Chalk. — The chalk, when mixed with clay, and 
permeable, forms a very healthy soil. The air is pure, and 
the water, though charged with calcium carbonate, is clear, 



i 



156 TEXT-BOOK OF HYGIENE. 



sparkling, and pleasant. Goitre is not nearly so common, nor 
apparently calculus, as in the limestone districts. 

"If the chalk be marly, it becomes impermeable, and is 
then often damp and cold. The lower parts of the chalk, which 
are underlaid by gault clay, and which also receive the drainage 
of the parts above, are often very malarious; and in America 
some of the most marshy districts are in the chalk. 

" 5. The Sandstones. — The permeable sandstones are very 
healthy; both soil and air are dry; the drinking-water is, how- 
ever, sometimes impure. If the sand be mixed with much clay, 
or if clay underlies a shallow sand-rock, the site is sometimes 
damp. I 

" The hard millstone-grit formations are very healthy, and 
their conditions resemble those of granite. 

"6. Gravels of any depth are always healthy, except when 
they are much below the general surface, and water rises through 
them. Gravel hillocks are the healthiest of all sites, and the 
water, which often flows out in springs near the base, being 
held up by the underlying clay, is very pure. 

" 7. Sands. — There are both healthy and unhealthy sands. 
The healthy are the pure sands, which contain no organic 
matter, and are of considerable depth. The air is pure, and so 
is often the drinking-water. Sometimes the drinking-water con- 
tains enough iron to become hard, and even chalybeate. The 
unhealthy sands are those which, like the subsoil of the Landes, 
in southwest France, are composed of silicious particles (and 
some iron) held together by a vegetable sediment. 

"In other cases sand is unhealthy from underlying clay or 
laterite near the surface, or from being so placed that water 
rises through its permeable soil from higher levels. Water may 
then be found within 3 or 4 feet of the surface ; and in this case 
the sand is unhealthy and often malarious. Impurities are 
retained in it and eflluvia traverse it. 

" In a third class of cases the sands are unhealthy because 
they contain soluble mineral matter. Many sands (as, for ex- 



CHARACTER OF THE SOIL. 157 

ample, in the Punjab) contain magnesium carbonate and lime- 
salts, as well as salts of the alkalies. The drinking-water may 
thus contain large quantities of sodium chloride, sodium carbon- 
ate, and even lime and magnesian salts and iron. Without 
examination of the water it is impossible to detect these points. 

"8. Clay^ Dense Marls^ and Alluvial Soils Generally. — 
These are always regarded with suspicion. Water neither runs 
off nor runs through ; the air is moist; marshes are common; 
the composition of the water varies, but it is often impure with 
hme and soda salts. In alluvial soils there are often alterations 
of thin strata of sand, and sandy, impermeable clay. Much 
vegetable matter is often mixed with this, and air and water are 
both impure. 

" The deltas of great rivers present these alluvial characters 
in the highest degree, and should not be chosen for sites. If 
they must be taken, only the most thorough drainage can make 
them healthy. It is astonishing, however, what good can be 
effected by the drainage of even a small area, quite insufficient 
to affect the general atmosphere of the place ; this shows that it 
is the local dampness and the efB.uvia which are the most 
hurtful. 

"9. Cultivated Soils. — Well-cultivated soils are often 
healthy ; nor at present has it been proved that the use of manure 
is hurtful. Irrigated lands, and especially rice-fields, which not 
only give a great surface for evaporation, but also send up 
organic matter into the air, are hurtful. In Northern Italy, 
where there is a very perfect system of irrigation, the rice- 
grounds are ordered to be kept 14 kilometres (8.7 miles) from 
the chief cities, 9 kilometres (5.6 miles) from the lesser cities and 
the forts, and 1 kilometre (1094 yards) from the smaller towns. 
In the rice countries of India [and America] this point should 
not be overlooked." 

Where a wet, impermeable, or impure soil must, of neces- 
sity, be chosen as a building-site, it should be thoroughly 
drained. The minimum depth at which drains are laid should 



158 TEXT-BOOK OF HYGIENE. 

be not less than 1^ metres below the floor of the cellar or base- 
ment. Such a soil should be covered with a thick, impervious 
layer of asphaltum or similar cement under the house, in order 
to prevent the aspiration of the polluted ground-air into the 
building. 

It is a frequent custom in cities to fill in irregularities of 
the building-site with street-sweepings and garbage, which 
always contain large quantities of decomposing organic matters. 
This is a gross violation of the plainest principles of hygiene. 
It is almost equally reprehensible to use such decaying or 
putrefying organic material for the purpose of grading streets 
or sidewalks in cities and towns.^ It should be the constant 
endeavor of all sanitary authorities to prevent pollution of the 
soil as much as possible in villages, towns, and cities. 

Where houses are built on the declivity of a hill, the upper 
wall should not be built directly against the ground, as it would 
tend to keep the wall damp. A vacant space should be left 
between the wall and the ground to permit free access of air 
and light. 

In addition to, or in default of, drainage, the drying of soil 
can be promoted by rapidly-growing plants, which absorb water 
from the soil and give it out to the air. The sunflower and the 
eucalyptus tree are the most available for this purpose. 

III. THE MATERIAL OF WHICH THE HOUSE IS BUILT. 

The nature of the most appropriate building material de- 
pends upon so many collateral circumstances that definite rules 
cannot be laid down. As a general rule, moderately hard 
burned brick is the most serviceable and available material. It 
is easily permeable by the air, and so permits natural ventila- 
tion through the walls, unless this is prevented by other means. 

* During the very fatal epidemic of yellow fever in New Orleans, in 1878, it was ascer- 
tained that a contractor for street-work used the garbap;e and street-scrapings to grade the bed 
of the streets. Even though in this case it may not have intensified the epidemic in these 
localities, the practice is so contrary to the simplest sanitary laws that it should nowhere be 
tolerated. The author is aware, however, that the "made-ground" of nearly every city in this 
country is composed largely of just such material. All sanitarians should protest against a 
continuance of this pernicious practice. 



MATERIAL OF TVHICII THE HOUSE IS BUILT. 159 

It does not absorb and hold water readily ; hence, damp walls 
are mfrequent if brick is used. It is probably, of all building 
material, the most durable. On account of its porosity a brick 
wall is a poor conductor of heat. It therefore prevents the 
rapid cooling of a room in cold weather, and likewise retards 
the heating of the inside air from without in summer. Another 
very great advantage is its resistance to a very high degree of 
heat, brick being probably more nearly fire-proof than any 
other building material. 

In hot climates light wooden buildings are advantageous, 
because they cool off" very rapidly after the sun has disappeared. 
On account of the numerous joints and fissures in a frame 
building, natural ventilation goes on very readily and to a con- 
siderable extent. 

Next to brick, granite, marble, and sandstone are the most 
serviceable building materials. Very porous sandstone is, how- 
ever, not very durable in cold climates, as the stone absorbs large 
quantities of water, which, in consequence of the expansion 
accompanying the act of freezing, produces a gradual but 
progressive disintegration. 

The application of paint to the walls, either within or with- 
out, almost completely checks the transpiration of air through 
the walls, thus limiting natural ventilation. Calcimining, on 
the other hand, offers very little obstruction to the passage of 
air. Wall-paper is about midway between paint and lime- 
coating in its obstructive efiect on atmospheric transpiration. 

Newly-built houses should not be occupied until the walls 
have become dry. Moisture in the walls is probably a not 
infrequent source of ill health; it offers favorable conditions for 
the development of fungi (possibly of disease-germs), and, by 
filling up the pores of the material of which the walls are 
composed, prevents the free transpiration of air through 
them. 

Moisture of the walls is sometimes due to the ascent of 
the water from the soil by capillary attraction. This can be 



160 TEXT-BOOK OF HYGIENE. 

prevented by interposing an impervious layer of slate in the 
foundation-wall. 

Where the moisture is due to the rain beating against the 
outside walls, and thus saturating them if composed of porous 
materials, a thorough external coating of impervious paint will 
prove a good remedy. 

ly. INTERIOR ARRANGEMENTS. 

A. Size of Eoo7ns, and Ventilating and Heating Arrange' 
ments. — The rooms in dwelling-houses should never be under 
2 J metres in height from floor to ceiling. In sleeping-rooms 
the initial air-space should never be less than 35 cubic metres 
for adults, and 25 cubic metres for children under 10 years of 
age. Provision must be made for changing this air sufficiently 
often to maintain it at its standard of purity; i.e.^ less than 7 
parts of carbon dioxide per 10,000. The details for accomplish- 
ing this will vary with the architects' designs, the material of 
which the house is constructed, the climate, and the season. 
The principles laid down in the section on ventilation (Chapter 
I) should be adhered to. In cold weather the air should be 
warmed, either before its entrance into the room or afterward, by 
stove or fire-place. Galton's jacketed stove, or fire-place, seems 
to answer this purpose admirably. The details of the heating 
apparatus must be left to individual taste, or other circum- 
stances. It may be noted, however, in passing, that the pre- 
vailing method of heating houses by means of hot air is objec- 
tionable for various reasons ; partly, because the air is usually too 
dry to be comfortable to the respiratory organs ; partly, because 
organic matter is frequently present in large proportions, and 
gives the air an offensive odor when the degree of heat is high 
enough to scorch the organic matter. Both these objections 
are, however, removable ; the first, by keeping a vessel of water 
constantly in the furnace, so that the hot air can take up a 
sufficient proportion of vapor in passing through, and, the second, 
by having the furnace made large enough so that the tempera- 



INTERIOR ARRANGEMENTS. 



161 



ture need never be raised to a very high degree. Heating by 
hot water or steam is preferable to the hot-air furnace. Both 
of these methods are, however, more expensive. 

Where special ventilating arrangements are necessary, air- 




FlG. 6. 

a, a, sash: b, b, window-jambs ; c, c, window- 
sill. This cut represents the view from 
within the Bury Ventilator, in operation. 
It is broken away at one end to show the 
sash raised above the outer holes to admit 
the air. 



Fig. 7. 

a, a, sash. This cut represents the view from 
without the Bury Ventilator, in operation. 
The sash is broken away to show the ven- 
tilator behind, with the fresh air passing 
in. 



inlets may be inserted at appropriate points in the walls of the 
room, facing toward the air. A simple arrangement is that known 
as the Bury Ventilator, shown in Figs. 6 and 7. It consists 
of a wooden block interposed between the bottom of the lower 



11 



162 



TEXT-BOOK OF HYGIENE. 



window-sash and the window-frame. The air passes into the room 
through the openings in the block, as shown in the illustration. 
The separation of the upper and lower sashes, when the ventilator 




is in place, also adds to the efficiency of the ventilation, as the 
air passes in through the space so formed. 

A cheaper ventilator can be made by simply tacking a strip 



INTERIOR ARRANGEMENTS. 163 

of canvas, binders' board, or manilla paper, 20 to 25 centimetres 
wide, across the lower portion of the window-frame, and then 
raising the sash 10 to 15 centimetres. The air will pass in 
under the lower and between the lower and upper sashes and 
pass upward toward the ceiling and then gradually diffuse itself 
through the room. In summer a counter-opening may be ob- 
tained for the escape of foul air by lowering the upper sash, 
while in winter a stove or fire-place will furnish a good exit. 

Fig. 8 shows the probable course of the air-currents in a 
room ventilated by means of a fresh-air inlet near the ceiling 
and an open fire-place. A is the inlet; the fire-place; G the 
floor ; jP, ceiling ; E E, flues. 

B. Internal Wall-Coating. — A point of considerable im- 
portance in the outfitting of dwelling-houses is the material 
used for coating or decorating the inside of the walls. Green 
paint and green-colored wall-papers should be rejected. The 
reason for avoiding this color is the following : Bright-green 
pigments and dyes are largely composed of some compound of 
arsenic, which becomes detached from the wall or paper when 
dry. and, being inhaled, produces a train of symptoms which 
have been recognized as chronic arsenical poisoning. Many 
cases have been reported in which serious and even fatal poison- 
ing has been produced in this way.^ It would be advisable, 
therefore, to discard all bright-green tints in paints and orna- 
mental paper-hangings. 

C. Lighting. — Provision should be made in all dwelHng- 
houses for an abundant supply of sunlight. Every room should 
have at least one window opening directly to the sun. It is not 
sufiicient to give an ample window-space, which should be in 
the proportion of one to five or six of floor-space, but the im- 
mediate surroundings of the house must be taken into account. 
Thus, close proximity of other buildings, or of trees, may pre- 
vent sufficient light entering a room, although the window- 

* Arsenic in Certain Green Colors, F. W. Draper. Third Annual Report Mass. State 
Board of Health, 1872, pp. 18-57. 



164 TEXT-BOOK OF HYGIENE. 

space may be in excess of that required under ordinary 
circumstances. 

Some form of artificial light will also be needed in all 
dwellings. Certain dangers are necessary accompaniments of 
all available methods of artificial illumination. The danger 
from fire is, of course, the most serious. This danger is prob- 
ably least where candles are used, and greatest where the more 
volatile oils (kerosene, gasolene) are employed. The use of 
candles results in pollution of the air by carbon dioxide and 
other products of combustion to a greater degree than when 
other illuminating agents are used ; they also give out a larger 
amount of heat in proportion to their power of illumination. 
Kerosene gives a good light when burned in a proper lamp, and 
is cheap, but the dangers from explosion and fire are consider- 
able. The danger from explosion can be greatly reduced by 
always keeping the lamp filled nearly to the top, and never fill- 
ing it near a light or fire. The danger of explosion is increased 
when the chimney of the lamp is broken, as then the tempera- 
ture of the metal collar, by which the burner is fastened to the 
lamp, is rapidly raised^ and the oil vaporized. If, at the same 
time, the lamp is only partially filled with oil, the space above it 
is occupied by an explosive mixture of air and the vapor of the 
oil. If this is heated to a sufficient degree an explosion will 
take place. ^ 

The use of coal-gas is probably attended by less danger 
than the lighter oils, but by more than other means of illumina- 
tion. In addition to the dangers from fire and explosions, which 
are inevitable accompaniments of defects in the fixtures, the 
escaping gas is itself exceedingly poisonous from the large 
amount of carbon monoxide it contains. It is, in fact, a very 
frequent occurrence in large cities that persons are killed by the 
inhalation of gas which has escaped from the fixtures or was 



» H. B, Baker, in Report Mich. State Board of Health, 1876, p. 48. 

2 See an instructive paper by Prof, B. C. Kedzie, in Report Mich. State Board of Health 
for 1877, p. 71 e« aeq. 



INTERIOR ARRANGEMENTS. 165 

allowed to escape from the burner through ignorance. That 
variety of illuminating gas known as "water-gas" is more dan- 
gerous to inhale than coal-gas owing to the larger proportion of 
carbon monoxide contained in it. The "natural gas" used as a 
fuel and illuminant in some places in the United States is espe- 
cially dangerous from the total absence of odor. The gas may 
escape in large quantity and fail to give notice of its presence 
except by an explosion, if ignited, or by producing asphyxia in 
those who incautiously venture into the air permeated by it. 

The electric light (Edison's incandescent system) is prob- 
ably open to less objection on the score of danger than any 
other of the illuminating systems mentioned. There is no trust- 
worthy evidence that the electric light has any unfavorable in- 
fluence on the vision, although Regnault supposed it would have 
a bad effect upon the ocular humors on account of the large 
proportion of the violet and ultra-violet rays it contained. In 
order to remove this objection Bouchardat advised the wearing 
of yellow glasses by those compelled to use this light for close 
work. The advantages of the incandescent light, besides the 
brilliant white liglit it gives, are that it is steady and does not 
produce any heat, nor does it pollute the air with carbon dioxide 
and other products of combustion. Professor von Pettenkofer 
has recently shown experimentally that the pollution of the air 
by the products of combustion is very much greater when gas 
is used than where the electric light is employed. The electric 
arc-lights are extremely dangerous on account of the high poten- 
tial maintained in the wires, and the difficulty of thoroughly 
insulating the latter. Many deaths have occurred from this 
source, and, unless a method is discovered and adopted by 
which the voltage of the arc-light current can be greatly dimin- 
ished without decreasing the efficiency of the light, this method 
of lighting must soon be given up in cities, owing to its danger, 
not only to those directly brought in contact with the conductors, 
but to others who may indirectly get in the way of the errant 
current. 



166 TEXT-BOOK OF HYGIENE. 

In writing, sewing, reading, or other work requiring a con- 
stant use of accurate vision, the light, whether natural or artifi- 
cial, should fall upon the object from above and on the left side. 
Hence, windows and burners should be at least at the height 
of the shoulder and to the left of the person using the light. 

Increased ventilation facilities must be provided where arti- 
ficial light (except the electric light) is used to any extent. It 
has been calculated that for every lighted gas-burner 12 to 15 
cubic metres of fresh air per hour must be furnished in addition 
to the amount ordinarily required in order to maintain the air 
of the room at the standard of purity. 

Y. WATER-SUPPLY. 

The water-supply of a dwelling-house should be plentiful for 
all requirements, and its distribution should be so arranged that 
the supply for every room is easily accessible. Where prac- 
ticable, water-taps should be placed on every floor, both for 
convenience and for greater safety in case of fire. It is also a 
result of observation that personal habits of cleanliness increase 
in a direct ratio with the ease of obtaining the cleansing agent. 
The inmates of a house where water is obtainable with little 
exertion are much more likely to be cleanly in habits than 
where the water-supply is deficient or not readily procured. 

VI. HOUSE-DRAINAGE. 

Provision must be made for the rapid and thorough removal 
of waste-water and excrementitious substances from the house. 
This is most easily and completely accomplished by well-con- 
structed water-closets and sinks. Water-closets should, however, 
not be tolerated in any room occupied as a living- or bed- room. 
It would doubtless be very much more in accordance with sani- 
tary requirements to have all permanent water-fixtures, water- 
closets, and bathing arrangements placed in an annex to the 
dwelling proper. In this way the most serious danger from 
water-closets and all arrangements having a connection with a 



HOUSE-DRAINAGE. 167 

cess-pool or common sewer — permeation of the house by sewer- 
air — could be avoided. 

Water-closets, however, presuppose an abundant supply of 
water. Unless this can be obtained and rendered available for 
flushing the closets, soil-pipe, and house-drain, the dry-earth or 
pail system should be adopted. Privies should not be coun- 
tenanced. Experience in several large cities of Europe has 
demonstrated^ that the pail system can be adopted with advan- 
tage and satisfactorily managed even in large communities. 

As house-drainage may be considered the first and most 
important link in a good sewerage system, a brief description 
will be here given of the details of the drainage arrangements 
of a dwelling-house. The rapid and complete removal of all 
fa3cal and urinary discharges, lavatory- and bath- wastes, and 
kitchen-slops must be provided for. For these purposes are 
needed, firsts water-closets and urinals, wash-basins and bath- 
tubs, and kitchen- or slop- sinks ; second^ a perpendicular pipe, 
with which the foregoing are connected, termed the soil-pipe; 
and, third, a horizontal pipe, or house-drain, connecting with the 
common cess-pool or sewer. 

A. Water- Closets — There are five classes of water-closets 
in general use. They are the pan-, valve-, plunger-, hopper-, and 
washout- closets. 

Pan-closets are those found in most old houses containing 
water-closet fixtures. Just under the bowl of the closet is a 
shallow pan containing a little water, in which the dejections 
are received. On raising the handle of the closet, the pan is 
tilted and the water at the same time is turned on, which washes 
out the excrement and sends it into or through the trap between 
the closet and the soil-pipe. It will be readily understood that 
the space required for the movement of the pan — the " container," 
as it is termed — is rarely thoroughly cleansed by the passage of 
water through it. Faecal matter, paper, etc., gradually accumu- 
late in the corners of the container, and, as a consequence, pan- 

1 See Chapter v, p. 139. 



168 TEXT-BOOK OF HYGIENE. 

closets are always, after a brief period of use, foul. There are' 
other defects in the construction of the pan-closet which render 
it untrustworthy, but the one especially pointed out — the impos- 
sibility of keeping it clean- — is enough to absolutely condemn its 
use, from a sanitary point of view. It is decidedly the worst 
form of closet that can be used. 

Valve-closets are merely modifications of the pan-closet. 
The bottom of the bowl is closed by a flat valve, which is held 
in its place by a weight. By moving a lever the valve is turned 
down, allowing the excreta to drop into the container. The only 
diflerences between the pan- and valve- closets are that in the 
latter a flat valve is substituted for the pan of the former, and 
that this allows the container to be made smaller. Otherwise, 
there are no advantages in the valve-closet. Considered from a 
sanitary stand-point, the valve-closet is no worse than the pan- 
closet, and but very little, if any, better. 

The third variety, or plunger-closet, has several marked 
advantages over the two just described. The characteristic 
feature of the closets of this class is that the outlet, which is 
generally on one side of the bowl, is closed by a plunger. This 
bowl is always from one- third to one-half full of water, into which 
the excreta fall. On raising the plunger, the entire contents of 
the bowl are rapidly swept out of the apparatus into the soil- 
pipe, the bowl thoroughly washed out by a sudden discharge of 
water, and, on closing the outlet with the plunger, the bowl is 
again partly filled with water. An overflow attachment prevents 
accumulation of too large a quantity of water in the bowl. Tliis 
overflow, however, sometimes becomes very foul and objection- 
able. The Jennings, Demarest, and Hygeia are types of this 
class. The principal objection is that the plunger sometimes 
fails to properly close the outlet, allowing the water to drain out 
of the bowl, and thus destroying one of its principal advantages. 
The mechanism is also somewhat complicated and likely to get 
out of order. 

The hopper-closet consists of a deep earthenware or enameled 



HOUSE-DRAINAGE. 



169 



iron bowl, with a water-seal trap directly underneath. The 
excreta are received directly into the proximal end of the trap, 
and when the water is turned on the sides of the bowl are 
washed clean and everything in the bowl and trap swept directly 
into the soil-pipe. There is no complicated mechanism to get 
out of order, the trap is always in sight, and the entire appa- 
ratus can always be kept clean and inoffensive, as there are no 
hidden corners or angles for filth to lodge. This form of closet 
is, all things considered, one of the best for general use. 




Fig. 9.— The "Dececo" Closet. (New Form.) 

The " wash-out " closets are of various shapes, some having 
the trap in the bowl itself, others having a double water- trap. 
They are generally simple in construction, and not likely to get 
out of order. They do not present any decided advantages over 
the simple hopper, although at the present time they are more 
used than any other form of closet. Of the recent improvements 
in this form of closet may be mentioned the "A. G. M.,"^ shown 

* Manufactured by the Myers Sanitary Depot, New York. 



170 



TEXT-BOOK OF HYGIENE. 




Fig. 10.— The "A. G. M." Closet. 



HOUSE-DRAINAGE. 



171 



in view with cistern in Fig. 10, and in section in Fig. 11, and 
the '• Dececo," Fig. 9, invented by Col. George E. Waring. 
In the latter the automatic siphon principle, so ingeniously used 
by Rogers Field in the construction of the automatic flush-tank, 
is appUed to the scouring of a water-closet. Practical experi- 
ence for six or seven years has demonstrated the great usefulness 
of this closet. If the dehvery of water from the flushing-cistern 
is properly regulated, at first rapid to thoroughly wash out the 




Fig. 11.— Sectionax, View of "A. G. M." Closet. 



closet and connections, and then slow to re-establish the proper 
depth of seal in the trap, the closet should be thoroughly satis- 
factory^ in its working. 

Water-closets should not be inclosed in wooden casings, as 
is almost universally done. Everything connected with the 
closet, soil- and drain- pipes, water-supply, and all joints and fix- 
tures should be exposed to view so that the defects can be imme- 
diately seen and easily corrected. By laying the floor and back 
of the closet in tiles or cement, such an arrangement can even 



172 TEXT-BOOK OF HYGIENE. 

be made ornamental, as suggested by Waring/ wbo says that a 
closet " made of white earthenware, and standing as a white 
vase in a floor of white tiles, the back and side walls being 
similarly tiled, there being no mechanism of any kind under 
the seat, is not only most cleanly and attractive in appearance, 
but entirely open to inspection and ventilation. The seat for this 
closet is simply a well-finished hard-wood board, resting on cleats 
a little higher than the top of the vase, and hinged so that it may 
be conveniently turned up, exposing the closet for thorough 
cleansing, or for use as a urinalor slop-hopper." 

Where the arrangement here described is adopted, extra 
urinals are unnecessary and undesirable. Where they are used 
they should be constantly and freely flushed with water, other- 
wise they become very oflensive. The floor of the urinal should 
be either of tiling or enameled iron. 

B. Water- Supply for Closets. — The water-supply for flush- 
ing water-closets should not be taken directly from the common 
house-water supply, but each closet should have an independent 
cistern large enough to hold a suflicient quantity of water for a 
thorough flushing (20 to 30 litres) every time the closet is used. 
The objections to connecting the water-closet directly with the 
common house-supply are, that there is often too httle head of 
water to properly flush the basin; and, secondly, if the water 
be drawn from a fixture in the lower part of the house, while 
the valve of a water-closet in an upper floor is open at the same 
time, the water will not flow in the latter (unless the supply- 
pipe is very large), but the foul air from the closet will enter 
the water-pipe, and may thus produce dangerous fouling of the 
drinking-water. Hence, separate cisterns for each water-closet 
should always be insisted upon. 

The arrangement of these cisterns is often difficult to com- 
prehend. Fig. 12 shows the interior arrangement of one form. 
The ball-shaped float, a, cuts off the supply when the tank is 
full, while opening the valve, 6, by means of the crank, c, dis- 

» Sanitary Condition of New York City, Scribner's Monthly, vol. xxii, No 2, June, 1881. 



HOUSE-DRAINAGE. 



173 



charges the water. The rounded annex, d^ contains enough 
water to partly fill the closet-bowl and trap after the contents 
have been washed out by the rapid flush. 

C. Traps. — Every water-closet, urinal, wash-basin, bath- 
tub, and kitchen-sink should have an appropriate trap between 
the fixture and the soil-pipe. The trap should be placed as 
near the fixture as practicable, as pointed out above; in the 
best forms of water-closet the bottom of the closet itself forms 
part of the trap. 




Fig. 12.— Flushing Cistern for Water-Closets. 

Traps differ in shape and mechanism. The simplest and 
usually efficient is the ordinary S-trap (Fig. 13). This trap is 
of uniform diameter throughout, and has no angles for the lodg- 
ment of filth. A free flush of water cleanses it perfectly, and 
it rarely fails to furnish a suflicient obstruction to the passage 
of sewer-air from the soil-pipe, unless the water has evaporated, 
or been forced out under a back-pressure of air in the soil-pipe, 
or been siphoned out, and thus the seal broken. 



174 TEXT-BOOK OF HYGIENE. 

The D-trap and bottle-trap are objectionable on account 
of the great liability of becoming fouled by filth lodging in the 
corners, while in the mechanical traps, like Bowers' ball-valve 
trap, Cudell's trap, and others of this class, there is always 
danger of insufficient seal by filth adhering to the valve, and 
thus preventing its exact closure. 

Most of the traps now furnished by the dealers in plumbers' 
supplies have an opening in the highest part for attaching a 
vent-pipe. It has been found that the seal in most traps can be 
broken by siphonage, if the pressure of air on the distal side 
(the side toward the soil-pipe) of the trap is diminished, or, on 
the other hand, by increase of pressure in the soil-pipe the 
water in the trap may be forced back into the fixture, and thus 
sewer-air enter the room. By providing for a 
free entrance and exit of air to the trap this 
>^**N^ breaking of the seal can be prevented. The 
/ /^ A ventilation of traps is, however, an evil, as it 
I ^^ y furnishes an additional means of evaporation, 

and when the fixture is not in frequent (daily) 
use the seal is sooner broken. The elaborate 
extra system of ventilation of traps, so generally 
insisted upon by plumbers and sanitary engineers, is unnecessary. 
If the soil-pipe is of the proper size and height, siphonage of 
traps will not be likely to occur. The waste-pipe connecting 
the fixture and the soil-pipe should be as short as possible; in 
other words, all water-closets, urinals, baths, and lavatories 
should be placed as near the soil-pipe as practicable, in order to 
have no long reaches of foul waste-pipe under floors or in 
rooms. 

Dr. E. S. McClellan has recently invented a trap which 
obviates many of the objections urged against all previous de- 
vices, and is intended to meet the defects of the S and other 
traps. It consists of a body containing a light, inverted cup, with 
its edges resting in an annular groove containing mercury, which 
forms an absolute seal against the escape of sewer-air. When 



Fig. 13.— S-Tbap. 



HOUSE-DRAINAGE. 



175 



a slight diminution of pressure occurs on the sewer side of the 
cup, the greater external pressure lifts the cup out of the 
mercury and permits a free inflow of air until the wonted 
equilibrium is re-established, when the cup drops back into the 
mercury by gravity, and effectually closes the trap against any 
outflow. With this trap siphonage of the seal is impossible. 
Fig. 1-4 shows this trap with the cup down, and Fig. 15 with 
the cup raised, allowing inflow of air. 

For an ordinary wash-bowl or bath-waste (which should 




Fig. 14.— Sectional View op Vent, with 
Cup ln Normal Position. 



Fig. 15.— Sectional View of Vent, with 
Cup Lifted Out of the Mercury 
BY THE Inflowing Current of Air 
Indicated by the Arrows. 



always be trapped), the Connolly globe- trap, shown in Figs. 16 
and 17, is an excellent fixture. It is impossible, under ordinary 
circumstances, to break the seal by siphonage. 

D. The Soil-Pipe, — The vertical pipe connecting the 
water-closets and other fixtures with the house-drain is called 
the soil-pipe. It should be of iron, securely jointed, of an equal 
diameter (usually 10 centimetres) throughout, and extend ii'om 
the house-drain to from IJ to 2 metres above the highest point 
of the house. The connections of all the waste-pipes from 
water-closets, baths, etc., should be at an acute angle, in order 



176 



TEXT-BOOK OF HYGIENE. 



that an inflow at or nearly at right angles may not produce an 
obstruction in the free passage of air up and down the soil-pipe. 
The diameter of the soil-pipe, at its free upper end, should not 
be narrowed; in fact, according to Col. Geo. E. Waring, the 
up-draught is rendered more decided if the upper extremity of 
the soil-pipe is widened.^ The internal surface of the pipe 
should be smooth, and especial care should be taken to prevent 
projections inward at the joints; otherwise, paper and other 





Fig. 16.— CoNNOLiiT Globe-Trap. 



Fig. 17.— Globe-Trap Attached to Basin. 



matters will adhere to the projections, and gradually obstruct 
the pipe. 

E. The ffouse-Drain. — The horizontal or slightly inclined 
pipe which connects the lower end of the soil-pipe with the 
sewer or cess-pool, the point of final discharge from the house, 
should be of the same diameter and material as the soil-pipe. 
The joints should be made with equal care, and the pipe should 
be exposed to view throughout while within the house-walls. 

» Am. Architect, p. 124, Sept. 15, 1883. 



HOUSE-DRAINAGE. 177 

If sunk below the floor of the cellar it should be laid in a 
covered trench, so that it may be readily inspected. The junc- 
tion between the vertical and horizontal pipe should not be at a 
right angle, but the angle should be rounded. The drain-pipe 
should not be trapped. This is contrary to the advice of sanitary 
authorities generally, but the author thinks it unadvisable to trap 
the drain-pipe. There should be no obstruction to the outflow 
of sewage from the house, and a trap in the drain-pipe is of no 
avail against the passage of sewer-air from the sewer or cess- 
pool into the soil-pipe, if the pressure of the air in the former 
is increased. Furthermore, if the passage of air backward and 
forward between the sewer and the external air at a suflicient 
height (above the roofs of houses, for example) is free and 
unobstructed, the sewers (or the cess-pool, as the case may be) 
will be better ventilated than if an obstruction to such free 
circulation, in the form of a trap, be placed in the drain-pipe. 

Nearly all sanitary authorities direct that an opening for 
the admission of fresh air — "fresh-air inlet" — should be made 
hi the drain-pipe, before its connection with the sewer or cess- 
pool. This is done with the view of having a constant current 
of fresh air entering near the base of the soil-pipe and passing 
upward through it. Theoretically the current ought always to 
pass in this direction. Practically, however, the current is 
found, at times, to pass the other way, and the foul air from the 
soil-pipe may be discharged into the air near the ground, where 
it would be much more likely to do harm than when discharged 
high up in the air beyond the possibility of being breathed. 

OFFICIAL SUPERVISION OF THE SANITARY ARRANGEMENTS OF 

DWELLINGS. 

In most cities and towns the municipal authorities have 
provided for an official inspection of buildings, to prevent neglect 
of precautions against fire and other manifest dangers to life. 
It is only very recently, however, that the authorities of some 
of the larger cities in this country have enacted laws to prevent 

12 



178 TEXT-BOOK OF HYGIENE. 

improper construction of house-drainage works. Although none 
of these laws or ordinances cover the subject completely, yet 
their proper enforcement must result in great advantage. 

AVithin the past few years, following the example of Edin- 
burgh, volunteer associations have been organized in various 
cities of this country, with the object of securing constant expert 
inspection and supervision of the drainage arrangements of 
dwellings and other necessary sanitary improvements. 

The good results accomplished by the Newport Sanitary 
Protection Society, the New Orleans Auxiliary Sanitary Associa- 
tion, and other similar bodies attest the usefulness of such 
organizations. 

[The following works are recommended to the student 
who desires a fuller knowledge on the subjects treated in this 
chapter : — 

W. H. Corfield, Dwelling-Houses, Their Sanitary Construction and 
Arrangements, N. Y., 1880. — Wm. Paul Gerhard, House-Drainage and 
Sanitary Plumbing, Fourth Report State Board of Health of R. I., 
1881. — Eliot C. Clarke, Common Defects in House-Drains, Tenth Annual 
Report Mass. State Board of Health, 1879.] 



CHAPTER VII. 

Construction of Hospitals. 

SITE. 

If the choice of a site for the habitations of healthy per- 
sons is a matter of vital importance, as was pointed out in the 
last chapter, it needs no argument to impress upon the reader 
the actual necessity of choosing a site with wholesome surround- 
ings for a habitation for the sick. In selecting a site for a hos- 
pital, therefore, it is of prime importance to avoid a location 
where unsanitary influences prevail. 

While a hospital should always be easily accessible, it is 
not desirable that it should be in a noisy or crowded part of a 
city. Where a hospital is primarily designed for the reception 
of accident or " emergency " cases, it is, of course, necessary to 
have it near to where accidents are likely to occur. In a city 
this will probably be in the most crowded and noisy part. 

The direction of the prevailing winds from the city should 
be avoided in selecting a site for a hospital. 

Free admission of sunlight and air must be secured to all 
parts of the hospital. An elevated location is therefore desir- 
able, although exposure to violent winds must, if possible, be 
avoided. 

The soil upon which a hospital is built should be clean, 
easily drained, with a deep-ground water-level, not hable to 
sudden oscillations. The neighborhood of a marshy or known 
malarious region should be avoided. 

THE BUILDINGS. 

The building area must be large enough to permit the 
construction of buildings in accordance with the modern recog- 
nized principles of hospital construction. Overcrowding is not 

(179) 



180 TEXT-BOOK OF HYGIENE. 

permissible, either of the grounds by buildings or of the build- 
ings by patients. 

Having determined the number of patients for whom pro- 
vision is to be made and the character of the diseases to be 
treated, an estimate must be made of the area necessary for a 
hospital. Taking into account all the buildings needed, the 
area required will be — for two or more storied buildings — not 
less than 30 square metres per bed. If one-story buildings 
are to be erected more space will be required, and if infectious 
diseases are to be treated in the hospital the above space-allowance 
must be doubled or trebled. In the new Johns Hopkins Hos- 
pital, in Baltimore, the area occupied by the buildings is 56,000 
square metres, and provision is to be made for 300 patients. 
This, covering, of course, the area occupied by the administra- 
tion building, nurses' home, kitchen, dispensary, operating and 
autopsy theatre, laundry, etc., gives an area of 187 square metres 
per bed. The actual allowance of floor space per bed is 11|- 
square metres ; for patients with infectious diseases the space- 
allowance is nearly treble, being 29 square metres. 

Within recent years the principles of hospital construction 
have undergone considerable modification. While formerly 
a large hospital consisted usually of one large, two or more 
storied building, in which all the various departments were 
comprised under one roof, the aim has recently been to scatter 
the wards as much as practicable consistent with reasonable ease 
of supervision and administration. Under the former plan, with 
large wards connected by common corridors and stairways, ease 
of administration was primarily secured ; in the latter, the 
most important object of a hospital, " a place for the sick to get 
well in," is more nearly attained. While many hospitals are 
still being constructed on the old plan, of a single block of 
several stories in height, nearly all sanitary authorities are 
agreed that the plan of separate pavilions of one or, at most, 
two stories, in which the buildings are entirely disconnected, or 
connected only by means of an open corridor for convenience of 



THE HOSPITAL BUILDINGS. 181 

administration, is best for the patients, and, leaving out of 
account the cost of the ground, is also the most economical. 

The recent development of the pavilion system of hospitals 
may be attributed largely to the success obtained in treating the 
sick and wounded in the simple barrack hospitals during the 
late war between the States. The army barrack hospital is the 
original type of the pavilion hospital of the present day. 

Each pavilion consists of one or two wards, containing 
from ten to thirty beds altogether. In each pavilion or ward is 
also a bath- and wash- room, water-closet, dining-room, scullery, 
attendants' room, and sometimes a day-room for patients able 
to be out of bed. 

The two-story pavilion is built on the same plan, and is 
generally adopted in cities, or where economy of space is desir- 
able for financial reasons, and where no infectious diseases are 
treated. Where practicable, one-story pavilions should always 
be adopted, as they are more easily heated, ventilated, and 
served than two-storied buildings. 

When a number of pavilions or wards are connected by a 
corridor with each other, and with a central or administration 
building and other service buildings, the aggregation constitutes 
a modem pavilion block-hospital. The Johns Hopkins Hos- 
pital, already referred to, is a model hospital of this class, and 
its plans should be studied in detail by all who are more par- 
ticularly interested in hospital construction. The general wards 
are in one- and two- story buildings, connected by a corridor with 
each other and with the administration and service buildings. 
In addition to two buildings containing private rooms and small 
wards for patients able to pay for the extra accommodations, 
there is a line of pavilions running from east to west. The 
corridor cuts all the pavilions near the north ends of the build- 
ings, separating the ward almost entirely from the service part 
of the building. This arrangement leaves the south, east, and 
west fronts of the wards entirely exposed to the sun's rays, — 
a very important advantage. The kitchen and laundry are at 



182 



TEXT-BOOK OF HYGIENE. 



opposite angles of the grounds, while the autopsy building is 
placed in the extreme northeast corner of the grounds, as far 
from all the wards as practicable. 

The free space between the separate pavilions should be at 



WOLFE ST. 



■ 

R 


L 


il:+ 


-M 




B 



broa^ jv^ay" 



Fig. 18.— Plan of Johns Hopkins Hospitaii. 

A. Administration Building. B. Female Pay-Ward. C. Male Pay-Ward. D. Male Surgical Ward. 
E. Female Surgical Ward. F. Male Medical Ward. G. Female Medical Ward. H. Gynaecological 
Ward. I. Isolating Ward. K. Kitchen. L. Laundry. N. Nurses' Home. O. Dispensary. R. Patho> 
logical Building. S. Stable. U. Amphitheatre. X. Apothecary's Building. Y. Bath-Houso. 



least twice the height of the building. In the Johns Hopkins 
Hospital, the space is 18 metres between the one-story common 
wards, which are 11 metres in height from the surface of the 
ground to the ridge of the roof. 



VENTILATION AND HEATING. 183 

VENTILATION AND HEATING. 

The cubic space (initial air-space) per bed in the wards 
should not be less than 1500 to 2000 cubic feet (42 to 56 cubic 
metres), and for surgical or lying-in cases and contagious dis- 
eases, 70 cubic metres should be allowed. The ventilating 
armngements should secure an entire change of the air two to 
three times in an hour. 

In most sections of the United States, natural ventilation 
can be relied on to keep the air in hospital wards pure (assum- 
ing, of course, the proper construction of the buildings). The 
windows, doors, and walls are important factors in securing this 
ventilation. Hence, especial care is to be paid to their con- 
struction and arrangement. 

Many German, French, and English authorities on hospital 
building urge the importance of making the walls impervious 
by cement, glass, or paint. The pecuhar odor known as " hos- 
pital odor," it is asserted, cannot be prevented in any hospital 
in which the floors, walls, and ceilings are not absolutely imper- 
vious. The American practice is generally in favor of walls 
which permit transpiration of air. In the experience of the 
author the imperviousness of the walls is not necessary to secure 
freedom from hospital odor. It remains a question for serious 
consideration whether the diminution of natural ventilation 
would not counterbalance any good resulting from non-absorp- 
tive walls. 

The interior of the walls should be perfectly smooth and 
plain; no projections, cornices, or offsets of any kind are per- 
missible. The desimbility of this restriction was clearly ex- 
pressed nearly a hundred years ago by John Howard : " From 
a regard to the health of the patients, I wish to see plain, white 
walls in hospitals, and no article of ornamental furniture intro- 
duced."^ 

Windows should run quite to the ceiling, and should not 
be arched, but finished square at the top. There should be one 

* An Account of the Principal Lazarettos of Europe, etc., p. 57. London, 179L 



184 TEXT-BOOK OF HYGIENE. 

window for every two beds. The window-sash should be double 
to retain heat, and the lights heavy, clear glass. Ventilation 
can be promoted by raising the outer sash from below and 
lowering the inner one from above. The insertion of a Sher- 
ringham ventilator at the top of the inner sash will aid in giving 
the incoming air-current an upward direction. 

Heating is best accomplished by introducing hot air from 
without, or by stoves or fire-places in the centre of the wards. 
Where hot air is introduced from without, it should be heated 
by passing it over steam- or hot- water coils, and not by passing 
it through a furnace, which may produce super-heating and 
excessive dryness of the air. 

In a series of experiments by Dr. Edward Cowles at the 
Boston City Hospital,^ the air was heated to 32° by passing it 
over steam-coils. It was admitted to the wards by numerous 
inlets 30 centimetres square. The best velocity for ventilating 
and warming purposes was found to be 54 metres per minute. 
Exit openings were in the ceiling, and it was found best to 
make them large, as by this means the rapidity of exit currents 
is reduced. 

Where the warming of the ward must be accomplished by 
stoves or fire-places in the ward, the best plan, for square and 
octagon wards, is to have a large central chimney with arrange- 
ments on the four sides for fire-places or stoves. This chimney 
can also be used as a very efficient ventilating shaft throughout 
the year by a device put in practice by Mr. John R. Neirnsee, 
architect of the Johns Hopkins Hospital.^ In oblong wards, 
two or more large stoves, placed at equal distances along the 
centre of the wards, will heat the wards effectually. 

Floors should be made of tiles, slate, or oak or yellow-pine 
lumber. If wood is used, it should be well seasoned, perfectly 
smooth, and all joints accurately made. The floor should be 
kept constantly waxed to render it impervious to fluids. 

» Report of the Massachusetts State Board of Health for 1879, pp. 231-248. 
2 Hospital Construction and Organization : Plans for Johns Hopkins Hospital, p. 335 
et seq. New York, 1875. 



VENTILATION AND HEATING. 185 

The space between the floor and ceiling below should be 
filled with some fire-proof non-conducting material, such as 
cement or hollow bricks, in order to isolate each floor or ward 
as much as possible from others, both to prevent transmission 
of noise and extension of fire. 

All corners and angles on the inside of the building should 
be rounded to facilitate the removal of dust. 

In cleaning up, care should be taken not to stir up the 
layers of dust too much by active sweeping or dusting. The 
floors, furniture, door- and window- casings should be wiped off 
with damp cloths. Soiled bedding, clothing, dressings, and 
bandages must be promptly removed from the ward. Mat- 
tresses and other bed-clothing should not be shaken in the ward.^ 

Water-closets or (where the dry method of removal of ex- 
creta is in use) earth- or pail- closets should be placed where 
they can be easily reached by the patients, but the apartment in 
which they are placed must not open directly into the ward. 
The entrance to this apartment should be from the corridor 
or, better still, from the open air. The ventilation of water- 
closets should be independent of and entirely distinct from 
that of the ward or other part of the hospital building. 

It is, of course, unnecessary to more than call attention to 
the vital importance of the prompt removal of all excreta, both 
solid and liquid, from the ward or hospital building. To at- 
tempt disinfection of excreta and allow them to remain in the 
ward after being voided is a pernicious practice, which should 
under no circumstances be permitted. All utensils for the re- 
ception of excreta, bed-pans, etc., should be immediately emptied 
and thoroughly cleansed. 

Urinals are not advisable ; the simple hopper-closet with 
hinged, hard-wood seat, as described in Chapter VI, is sufficient. 

A bath-room and lavatory should be attached to every 
ward. It should be placed in the service building, and be 

^A "Wernich : Ueber Verdorbene Luft in Kraukenraeumen. Volkmann's Samml. Klin. 
Vortr., No. 179, p. 24. 



186 TEXT-BOOK OF HYGIENE. 

easily accessible to the patients. There should also be portable 
bath-tubs in order that baths may be given in the wards when 
necessary. 

Every large general hospital should also have a special 
apartment or building where baths of various kinds, such as 
medicated, vapor, Turkish, and Russian baths, could be given. 
In lying-in hospitals, special arrangements for giving vaginal 
and uterine douches must also be furnished. 

A daily water-supply of at least 450 litres per bed should 
be provided. The water should be easily accessible from the 
wards and various parts of the service building. 

All water-closets, soil- and waste- pipes must be properly 
trapped ; all joints must be properly made and all sewer con- 
nections made on the most improved plans. All work of this 
sort should be properly tested before being accepted, and 
frequently inspected afterward. 

No sewer or house-drain should be laid under a ward. 

A disinfecting chest for disinfecting soiled clothing, bed- 
ding, dressings, etc., should be placed in the basement of the 
ward, and connected with the latter by an iron chute, closing 
perfectly by an iron top. The best and most convenient disin- 
fectant is steam. This is also the best means to destroy vermin 
in clothing and bedding. 

It is questionable whether a nurse's room should be 
attached to a hospital ward. The nurse's place, when on duty, 
is in the ward itself, not in a room separate from it. Wliere 
there is a nurse's room, it should not be furnished with sleeping 
arrangements, for this is a strong temptation to neglect of duty 
on the part of the nurse. A nurse not on duty should not be 
permitted to remain about the ward. 

A ward-kitchen should be in the service building, where 
articles of food can be kept hot or cold when necessary, and 
where special dressings, cataplasms, hot water, etc., can be pre- 
pared. A small gas-stove only should be allowed in the ward- 
kitchen, as the regular meals of the patients are prepared in the 



ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 187 

central kitchen, which should be totally detached from the 
hospital. The ward-kitchen can be easily utilized as a nurse's 
room, and in a small hospital can also be used as a store-room 
for the patients' body- and bed- linen and clothing. 

The dining-room for patients able to be out of bed should 
be in the service building. A room with a good light and well 
ventilated and heated should be selected for this purpose. In 
the intervals between meals this room could be used as a day- 
room for such patients as should be out of bed, but who are not 
able to be in the open air. 

A dead-house, containing a dead-room, autopsy-room, and 
a room fitted up for rough microscopic and possibly photo- 
graphic work, is a necessity to every well-appointed general 
hospital. The dead-house should be entirely separate from the 
ward buildings. 

The kitchen should be separate from the other buildings, 
and in large hospitals should also be the central station for the 
heating arrangements, if hot water or steam are to be used. The 
laundry may be connected with it. The kitchen should be con- 
nected with the wards by means of a covered corridor to avoid 
exposure in carrying the food to the wards. 

The administration building should contain office-rooms 
for the superintendent and resident physician, pharmacy, library, 
reception-rooms for visitors, living-rooms for one or more assist- 
ants, and dwellings for the superintendent and resident physician. 

THE ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 

The general management of a hospital should be under the 
direction of a superintendent, who, besides being a medical man, 
should be especially qualified by study and experience for the 
work. The superintendent of a large hospital should not be 
expected to perform any of the routine professional work in the 
wards, but he should be responsible for the service, both profes- 
sional and lay, in the hospital. He should be the financial 
officer, and in all other things concerning the hospital his 



188 TEXT-BOOK OF HYGIENE. 

judgment should decide. He should have sufficient assistance 
to permit all necessary duties to be promptly performed. For 
this purpose he should have a secretary, or clerk, who should 
not be a medical man; otherwise the attention of the latter 
might be withdrawn from his clerical duties to the more inter- 
esting professional work in the hospital. The plan advocated 
by some authorities, to have two superintendents for large hos- 
pitals, — one of whom shall be a medical man and direct only the 
professional work of the hospital, while the other shall have 
charge of the administrative functions, — does not commend itself 
to the author. It involves a division of responsibility which will, 
in nearly all cases, eventually lead to differences of opinion 
likely to prove unfavorable to the best interests of the hospital. 

It is customary in this country to appoint as resident physi- 
cians and surgeons in hospitals, recent graduates, whose functions 
are usually limited to carrying out the directions of the visiting 
physicians and surgeons, and sometimes to act on their o\vn 
responsibility in emergencies. This system has some advantages 
for the physicians, but is usually detrimental to the best interests 
of the patients. The resident medical officer in a large hospital 
should always be a thoroughly qualified, experienced physician, 
capable of deciding promptly when the occasion arises, and he 
should be responsible to the superintendent for the proper per- 
formance of his professional duties. Necessarily, a physician 
with the qualifications indicated, would demand a very much 
larger salary than is usually paid resident physicians, but it 
should be understood that no hospital in which the good of 
the patient is the first consideration can be conducted on a cheap 
basis. 

Visiting physicians and surgeons and all resident medical 
officers should be chosen with reference to their general and 
special qualifications for the duties expected of them. It would 
seem to be a good plan to make the selections for subordinate 
positions, at least, by competitive examination. 

The sick in a hospital should be properly classified. Male 



ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 189 

and female patients should, of course, be treated in separate 
wards. A primary classification into medical, surgical, and 
obstetrical cases or wards is also indicated. Infectious dis- 
eases, such as typhoid fever, erysipelas, cholera, yellow fever, 
croupous pneumonia, etc., should not be treated in the same 
wards with rheumatism, Bright's disease, cardiac and nervous 
disorders, or simple digestive derangements. It is questionable, 
however, whether it is advisable to make a very elaborate classi- 
fication of the various diseases except in very large hospitals. 

An accurate record, made at the time of observation, and 
not written from memory afterward^ should be kept of the his- 
tory and progress of every case. The record should show not 
merely the symptoms and diagnosis, but the medical and hy- 
gienic treatment. In most hospitals where such records are 
kept the entries are made either in a simple memorandum-book 
or in a more or less complicated case-record. A simple form 
of case-record has been devised by Surgeon Walter Wyman, 
United States Marine Hospital Service, which seems to possess 
advantages that render its general adoption desirable. 

The following convenient form of record for obstetric cases 

is used in the Maryland Matemite under direction of the 

author : — 

Table XIX. 

Obstetric Case-Record of Maryland Maternite. 

Name 

Date of Admission 

Registered No Confinement No 

Labor began, Date Hour Minute 

Date of Delivery Hour Minute 

Previous Confinements 

EXTERNAL MEASUREMENTS OF PELVIS. 

Between Anterior S. S. Processes 

Between Widest Part of Iliac Crests 

External Conjugate Diameter 



DURATION OF LABOR AND CHARACTER OF PAINS. 

1st Stage Hours Minutes • • • 

2d Stage Hours Minutes 

3d Stage Hours Minutes 



190 



TEXT-BOOK OF HYGIENE. 



Rupture of Membranes Hour . . . 

Maternal Pulse During Pains Between Pains. . . , 

Drugs Used Quantity When . 

Operations Performed 

Pelvis Cervix Perinseum . 

Date of Beginning Milk Flow 

Pulse and Temperature for Same Date For Previous Day. 

Method of Delivery of Placenta 

Position when Delivered 

Weight Length 

Breadth Thickness 

Shape 



Minute 



Time of Tying Cord Length 

Spiral Point of Insertion 

Knots .Varicosities . . . 



Urine Before 
Labor. 



1st Day 
After Labor. 



8th Day 
After Labor. 



Specific Gravity . 
Reaction .... 
Albumen, per cent 

Sugar 

Chlorides .... 



PULSE AND TEMPERATURE. 



1st day 

2d " 

3d " 

4th " 

5th " 

6th " 

7th " 

8th " 

9th " 

10th " 



7 P.M. 



CHILD. 

Presentation and Position Sex 

Foetal Heart Between Pains During Pains .... 

Caput Succedaneum Respiration 

Circulation Temperature 

Weight at Birth 3d Day 6th Day 

Method of Feeding 



MEASUREMENTS. 



Length at Birth Length 4th Day 



ADMINISTRATION AND MANAGEMENT OF A GENERAL HOSPITAL. 191 



DIAMETERS. 





At Birth. 


4th Day. 


Occipito-Frontal 






Occipito-Mental 

Suboccipito-Breo"matic 




Biparietal 








CIRCUMFERENCES. 


■♦ 


At Birth. 


4th Day. 


Occipito-Frontal . 

Suboccipito-Breffmatic 






Shoulders 

Hips .... 













Discliarged . . 
Name of Nurse 



In hospitals where cases of surgical diseases and injuries are 
received, a special apartment should be fitted up as an operating 
room. Operations should not be performed m a ward in the 
presence of other patients. 

[The following works are recommended for additional study 
upon this subject: — 

Hospital Construction and Organization ; New York, 1875 (espe- 
cially the essays of Drs. Billings, Folsom, and Stephen Smith). — Kran- 
kenanstalten,by L. Degen, in Y. Pettenkofer und Ziemssen's Handbuch 
der Hygiene. — Spital, by C. Bohm, in Realencyclopadie d. ges. Heil- 
knnde, Bd. XII. — General Principles of Hospital Construction, by F. H. 
Brown, in Buck's Hygiene and Public Health, vol. i.] 



CHAPTER YIII. 

Schools. 

The hygiene of schools comprises the consideration of the 
sanitary principles underlying the construction of school-houses 
and school-furniture; the proper amount of time to be devoted 
to study at different ages ; the special diseases of school-children, 
their causes, and means for their prevention. 

CONSTRUCTION" OF SCHOOL-HOUSES. " 

In the construction of school-houses the same hygienic 
principles are applicable as in dwelling-house construction. The 
selection of a site for the school-building should command the 
same careful consideration that is necessary in determining upon 
a site for a dwelling. Proximity to marshes and other unsan- 
itary surroundings should be avoided. If the soil is damp it 
should be properly drained, and all sources of insalubrity in the 
neighborhood avoided or, if possible, removed. 

School-houses should not be over three stories high ; cor- 
ridors and stairways should be wide, straight, and well lighted. 
All stairs should be securely built, and be guarded with ample, 
strong railing. All doors should open outward to permit ready 
egress and reduce the danger of accident in panics from any 
cause. 

In addition to the study- or recitation- rooms, provision 
should be made for play and calisthenic-exercise rooms. Well- 
lighted and ventilated side-rooms should be provided for the 
reception of outside clothing, umbrellas, overshoes, etc. These 
articles should not be kept in the recitation- or study- rooms. 

Floors should be made of accurately-joined flooring, and 
rendered impervious by oil or paraffine coating. 

^^ (193) 



194 TEXT-BOOK OF HYGIENE. 

Appropriate measures must be employed to prevent the 
permeation of the building by ground-air. 

The inside walls of school-rooms may be tinted a neutral 
gray, or light blue or green. Ceilings should be white. Walls 
and ceilings should not be painted, but lime-coated to permit 
free transpiration of air. 

Schools should be so constructed as to permit of ready 
heating and ventilation, cleaning, and keeping clean. In large 
schools the method of heating will usually be by furnace-heated 
air, although a better method would probably be by steam- 
or hot-water pipes. 

The ventilation of school-rooms must be carried out on the 
principles indicated in Chapter I. With careful and intelligent 
teachers, natural ventilation will give better satisfaction than a 
complicated artificial system. Where windows and doors must 
be largely depended upon for ventilation, the Bury window ven- 
tilator, illustrated on a previous page, will give satisfactory results 
unless the school-room is overcrowded. Opening the doors and 
windows when the pupils are out of doors — flushing the rooms 
with fresh air — is an excellent aid, and is even useful in cases 
where the most elaborate artificial system of ventilation is in use. 

A model study-room, according to modern views, should 
be about 9 to 10 metres long, not over 7 metres wide, and 4 to 
4 J metres high. Such a room could be easily lighted by win- 
dows on one side only, and readily heated and ventilated. It 
would also enable the teacher to exercise a close supervision 
over his pupils. In a room of this size forty pupils would be a 
proper number, although fifty could be accommodated. The 
initial air-space for each pupil would be 5.60 cubic metres if 
there were fifty pupils in the room, and 7 cubic metres if 
there were only forty. This would be slightly reduced by the 
allowance for the teacher. 

It is believed that study-rooms should face toward the 
north. The light entering from the north side of a building 
would be equable during a whole day. While a larger window 



CONSTRUCTION OF SCHOOL-HOUSES. 195 

surface would be necessary than with an easterly or southerly 
exposure, it is held that the light, being devoid of all glare, 
would be more effective. Where the light is admitted on the 
east, south, or west sides of the building, the direct entrance of 
the sun's rays must be prevented by curtains, by means of which 
the amount and proper distribution of the light is regulated 
with difficulty. 

The windows of the school-room should reach from about 
the height of the pupil's shoulder (when seated) to nearly or 
quite to the ceiling. Arches or overhanging cornices over the 
windows should be avoided, as they cut off much light. For 
the same reason the near proximity of other high buildings 
and of trees should be avoided in selecting a site for a school- 
house. The window area should be not less than one-fifth of 
the floor area, otherwise the light will be deficient. 

The light should be admitted only from the left side of the 
pupil. When admitted from the right side the shadow cast by 
the pen in writing interferes with good vision ; if admitted 
directly in front of the pupil, the glare of the light will injuri- 
ously affect the eyes ; while, if it enter from behind, the book 
or paper of the pupil will be so much in shadow as to compel 
him to lean so far to the front in bringing his eyes nearer to 
book or paper that nearsightedness is very likely to be devel- 
oped. Furthermore, if the light is admitted into the room at 
the backs of the pupils, the eyes of the teacher are liable to 
suffer from the constant glare. 

In a school-room of the dimensions above stated, a row of 
windows on one side, forming an area of glass one-fifth of the 
floor-space, will thoroughly and satisfactorily illuminate the 
room, with the least unfavorable influence upon the organs of 
vision. It is advisable, therefore, to always insist on this 
arrangement of lighting of school-rooms. Where artificial 
light is used in a school-room, it should be in the proportion 
of one burner to every four pupils. All burners should be 
provided with chimneys and vertical reflectors. 



196 TEXT-BOOK OF HYGIENE. 

Water-closets and privies should not be placed in cellars or 
basements. This would seem to be self-evident, and yet in 
many city school-houses these places of retirement are in this 
unsuitable location. When it is considered that large schools 
are frequently warmed by hot air taken from the cellar, it 
furnishes an additional reason to avoid this location for water- 
closets. On the contrary, the custom, in some country schools, 
of placing the privy at a considerable distance from the school- 
room and in an exposed situation, is almost equally reprehen- 
sible, as the pupils, especially girls, are prone to neglect obeying 
the calls of nature, from which neglect many disorders arise. 

In a recently-introduced system of ventilation and excre- 
ment removal for schools, the closets are in the basement, and 
the excrement, as voided, is rapidly dried by a current of air, 
and the odor in this way quickly destroyed. Unfortunately, in 
thus drying the excrementitious matter, micro-organisms may 
be taken up in the air-currents and carried into the school-rooms. 

SCHOOL FURNITURE. 

Desks should be slightly sloping, the edge nearest the pupil 
being about 1 inch (2.5 centimetres) higher than his elbows. 
The front edge of the seat should project a little beyond the 
near edge of the desk, so that a plumb-line dropped from the 
latter should strike the seat near its front edge. If the seat is 
not thus brought slightly under the desk, the pupil is compelled 
to lean forward in writing, which position prevents proper ex- 
pansion of the chest and increases the blood-pressure in the 
eyes, — a condition promotive of near-sightedness. 

Seats should be only high enough so that the feet rest fiat 
upon the floor. If they are higher, a foot-board must be pro- 
vided. Children should not be condemned to the cruelty of 
having their feet dangling " between heaven and earth " while 
they keep their seats. Seats and desks should be graded 
according to the sizes of the pupils — not their ages or standing 
in the class. 



SCHOOL FURNITURE. 



197 



An ideal seat and desk would be one made to measure for 
each pupil, but this is manifestly impracticable, inasmuch as 
with the constant growth of the child the seats would be rapidly- 



outgrown. 



The desk shown in Fig. 19 Ms adjustable to children of 
different sizes, and seems to solve the problem wdiich has so long 
puzzled the school sanitarian. The desks are made for a single 
pupil and the seat and desk are independently adjustable. 




Fig. 19.— Adjustable School-Desk. (Front View.) 

The frame is of iron and the seat, back, and desk of hard-wood 
lumber. 

Blackboards should not be placed at a greater distance than 
10 metres from the farthest pupil. The ground of the board 
should be a dead black, without lustre. In writing exercises 
upon the board, care should be taken that the letters and figures 
are made sufficiently large, and with rather heavy strokes of the 
crayon, in order that they may be easily seen from the most distant 
part of the room. It has recently been demonstrated that a black 
letter on a white ground can be seen at a greater distance than 

1 Made. by the Rushville Scliool Furniture Company, Rushville, Ind., U. S, A. 



198 TEXT-BOOK OF HYGIENE. 

a white letter on a black ground. Hence, it might prove 
advantageous to the eye-sight of school-children to substitute 
for the present blackboard and chalk, a white board and black 
crayon. In some European lecture-rooms this plan has been 
adopted with satisfaction. 

AMOUNT OF TIME TO BE DEVOTED TO STUDY. 

Young children should not be kept at the same study or 
in the same position for long at a time. The exercises should 
be frequently varied. It is especially with children in the 
primary grades that care should be taken not to overburden 
their minds Avith too many hours of study, or too long con- 
tinuance at the same exercise. 

Children should not be placed in school much, if at all, 
before the completion of their 7th year. From 7 to 9 years 
they should be kept at their studies not longer than three hours 
daily; from 9 to 12 years four hours may be allotted them; and 
from 12 to 16 years they may be kept at mental work five to six 
hours daily. This does not mean that pupils are to be kept 
continuously at their studies during these hours, but that they 
should be neither compelled nor permitted to study longer than 
these periods each day. It is believed that these figures repre- 
sent the capacity for endurance in the majority of children, and 
they should be adopted in all schools where the largest return 
in mental acquirements is desired at the least expenditure of 
health. Excess of time expended in study is almost certainly 
followed by physical deterioration. "A little less brain: a little 
more muscle," for our children, is a legitimate demand that we 
may make of legislators and school-boards. 

Gymnastic exercises should form part of the daily routine 
in all schools. These exercises should take place, when practi- 
cable, in the open air. Playing, romping, laughing, and sing- 
ing should be encouraged, rather than the natural tendency 
to boisterous play restrained. It is especially desirable that 
female children should be encouraged to take part in these 



DISEASES OF SCHOOL-CHILDREN". 199 

diversions. The desire, on the part of many parents, to see 
little girls deport themselves as young ladies, before the time 
even when they write their age in two figures, is very rep- 
rehensible, and deserves the most unqualified condemnation. 
Moliere's satirical remark, " II n'ya plus d'enfants," seems to 
be literally true at the present day. 

DISEASES OF SCHOOL-CHILDREN". 

The principal diseases incident to school-life are myopia, 
spinal deformities, nervous and digestive disorders, pulmonary 
phthisis, and contagious diseases. It is believed that by judi- 
cious sanitary measures these can all be very much diminished 
and some entirely prevented. 

It has been shown by the examination of the eyes of school- 
children that near-sightedness increases progressively from the 
lowest to the highest classes. Children who enter school with 
an hereditary tendency to myopia, or who are, perhaps, already 
near-sighted to a slight degree, soon become more intensely 
myopic ; while others, who may be even hypermetropic on enter- 
ing school, will be found to have become near-sighted during 
school-life. In examinations of over 30,000 pupils of grammar 
and high schools in Germany, Austria, Russia, and Switzerland, 
it has been found that the average proportion of near-sightedness 
is a fraction over 40 per cent., varying, in the different classes, 
from 22 per cent, for the lowest to 58 per cent, for the highest 
classes. These figures represent the averages of all the ex- 
aminations made. In some particular schools, for example in 
the gymnasium (high school) of Erlangen, the percentage in the 
higher classes was 88 per cent., in the gymnasium of Coburg 
86 per cent., and in the gymnasium of Heidelberg the propor- 
tion of myopic students in the highest class is said to have 
reached 100 per cent, in 1877. In the primary schools the per- 
centage was found to be much lower. Recent investigations in 
the schools of Stockholm, by Widmark, show that among 
school-children examined under 7 years of age there was no 



200 



TEXT-BOOK OF HYGIENE. 



myopia. In the higher classes the myopia increases not only 
in degree, but in frequency. The diagrams, Figs. 20 and 21, 
show graphically the increase in degree and frequency of 
myopia in the several school-classes. These observations show 
that the number of myopic individuals bears a constant relation 
to the intensity of use of the visual organs. The results of the 
observation of different observers in different countries also 




Fig. 20.— Myopia According to School-Classes— Boys. 

uniformly point to the conclusion that not only does the number 
of near-sighted pupils increase as the higher classes are reached, 
but the degree of myopia increases likewise. Thus, a pupil 
who may have only a moderate degree of myopia on entering 
the school will have myopia in a higher degree as he advances 
in his classes. Erismann found, on re-examining tlie same 
pupils annually, that in six years 13.14 per cent, of those ex- 
amined had developed myopia from emmetropia, while in 24.57 



DISEASES OF SCHOOL-CHILDREN. 



201 



per cent, of near-sighted pupils the degree of myopia had 
increased.^ 

The principal causes of the prevalence of near-sightedness 
in schools are badly-arranged or insufficient light, bad air, over- 
heating of the school-rooms, improper construction of desks 
compelling children to lean forward while reading or writing, 
and badly-printed text-books. The use of small type, poor 
paper, and bad press-work in text-books is very reprehensible. 
The type technically known as Long Primer is the smallest that 




Fig. 21.— Myopia According to School-Classes— Girls. 

should be used m text-books. That badly-arranged light and 
improper seats are causes of myopia has been shown by Flor- 
schutz in his examinations of the pupils in the public schools 
of Coburg. He found that in the newer schools, in which the 
light and seats are better arranged, the percentage of near-sight 
decreased. The average percentage of those examined in 1874 
was 21, while in 1877 it had been reduced to 15,^ showing 

* Erismann, Die Hygiene der Schule, in von Pettenkoffer und Ziemssen's Handbuch der 
Hygiene, II Th., 2 Abth., p. 30. 

3 Quoted by Cobn in Realencyclopasdie d. ges. Heilk., Bd. XII, p. 263. 



202 TEXT-BOOK OF HYGIENE. 

the great improvement due to the application of correct sanitary 
principles in the construction of school-houses. 

Defective hearing has recently been shown to be especially 
frequent among school-children. A Berlin aurist found 1392 
children out of 5902 (23.6 per cent.) suffering from ear disease 
of some kind. Dr. Samuel Sexton, of New York, and the late 
Dr. Chas. F. Percivall, director of music in the public schools 
of Baltimore, have arrived at similar results after examination 
of a large number of school-children. 

Spinal curvature is present in a large proportion of the 
children attending schools. Statistics are not very full upon 
this subject, but one author, Guillaume, states that he found 
lateral curvature of the spine in 218 out of 731 school-children, 
— a proportion of 29.5 per cent. This, of course, includes the 
slighter degrees of curvature, which cannot properly be termed 
a disease. Among 30,000 Danish school-children 13 per cent, 
had some variety or degree of spinal deformity. M. Eulen- 
burg^ found that among 1000 persons with lateral curvature of 
the spine, the disease began in 887 between the ages of 6 and 
14 ; that is to say, during the years of school-life. Girls are 
affected more than ten times as often as boys, the proportion 
being 93.43 per cent, in the former and only 6.57 per cent, in 
the latter. 

The especial causes of spinal curvature occurring during 
school-life are improperly-constructed seats and desks and an 
improper position of the body. Many pupils habitually assume 
a " twisted " position, which is very liable to produce spinal dis- 
tortion in children of weak muscular development. The manner 
in which a desk that is too high for the pupil may produce 
spinal distortion is very well shown in Fig. 22. An improper 
position is more likely to be unconsciously assumed by girls than 
by boys. The clothing is responsible for this, for when the girl 
files into her place behind the desk, her clothing, hanging 
loosely about her, is swept back and forms a pad, upon which 

* Realencyclopaedie d. ges. Heilk., Bd. XI, p. 564. 



DISEASES OF SCHOOL-CHILDREX. 



203 



she sits with one buttock. The greater elevation of her seat 
on that side throws the spinal column out of the vertical line, 
which is compensated by a partial twisting of the trunk. Tlie 
attention of teachers should be directed to this faulty habit, 
which can be easily corrected, and its consequences averted by 
timely interference. 

Nervous disorders are comparatively frequent among school- 
children. Headaches are often due to insufficient ventilation, 
improper food, bad digestion, and excessive mental strain. 
Defective light may also be the cause of headaches by causing 




Fig. 22.— Shotttstg I>'Fi.rExcE of a High Desk in Causing Spinal CrKVATrRE. 

ocular fatigue. Hysterical and imitative affections are not 
infrequent, and sometimes pass through entire schools, including 
even the teachers. Girls are, of course, more subject to this 
class of disorders than boys, but the latter are not entirely 
exempt. 

Derangements of the digestive organs are exceedingly 
frequent among school-children. They can generally be traced 
to the use of improper food. The eating of cold lunches should 
be discouraged as much as possible. 

Nuts, candies, pies, fruit-cakes, and, above all, pickles are 



204 TEXT-BOOK OF HYGIENE. 

most fruitful sources of digestive derangements of children. 
The absence of proper accommodations to enable children — 
especially girls — to answer the demands of nature are frequent 
sources of digestive and nervous disorders. 

The seeds of pulmonary consumption are frequently im- 
planted during school-hfe. A neglected cough ; bad ventilation, 
under which term may be comprised overheating and cold 
draughts, as well as polluted air; improper position of the 
body, excessive mental work, or underfeeding, may, any of 
them, be the starting-point of this fatal disease. 

Especial care should be taken to prevent the introduction 
or dissemination of contagious diseases through schools. The 
importance of this duty should be at all times impressed upon 
school-boards and teachers. In the first place, no child should 
be admitted within the door of the school-room imless it first 
presents undoubted evidence of protection against small-pox, 
either by having passed through a previous attack or by a 
proper vaccination. In case of an actual or threatened epidemic 
of small-pox the entire school, including teachers, should be 
vaccinated. 

Diphtheria has been shown to be frequently spread through 
the agency of schools.^ This fatal disease demands especial 
precautions on the part of teachers and others involved in the 
management of schools, to prevent its introduction to these 
institutions. 

Children should not be admitted to school coming from a 
house where there is at the time, or has recently been, a case of 
contagious disease, such as small-pox, diphtheria, scarlet fever, 
or measles. At least four weeks should be allowed to elapse 
after the termination of such disease before a child from the 
infected house is re-admitted to the school. It goes without 
saying that no child having itself been sick with a contagious 
disease should be admitted to school until entirely restored to 

* The Relations of Schools to Diphtheria and to Similar Diseases, H. B. Baker, Public 
Health, vol. vi, p. 107. 



DISEASES OF SCHOOL-CHILDREN. 205 

health. The aforesaid limit of four weeks is the briefest period 
allowable before the quarantine of the infected house (so far as 
the schools are concerned) can be relaxed. 

When a case of contagious disease has accidentally obtained 
entrance to the school, the pupils should be dismissed for the 
day, and the room thoroughly disinfected by means of sulphur, 
chloriiie, or, what is better, scrubbing and spraying with solution 
of mercuric chloride. 

Teachers are not infrequently guilty of the grave impru- 
dence of sending pupils from the school to the house of an absent 
child to inquire the reason of the latter 's non-appearance at 
school. It frequently happens that the absent child is sick, and 
the messenger is invited to the sick-room to see his or her class- 
mate. There can be no room for doubt that scarlet fever, 
diphtheria, and measles have often been introduced into schools 
in consequence of such thoughtlessness on the part of teachers. 

In order to promote the proper hygienic management of 
schools, all teachers should be required to submit to an exami- 
nation in the principles and practice of hygiene, at least so far 
as school hygiene especially is concerned. This is a demand 
that school-boards could reasonably insist upon, and there can 
be no question that the improvement in the health of the pupils 
would amply justify the innovation. 

[Students may consult with advantage the following special 
articles : — 

D. F. Lincoln, School H3'giene, in Buck's Hygiene and Public 
Health, vol. ii, and Lomb Prize Essay on Scliool Hygiene, Concord, 
N. H., 1887. — F. Erismann, Die H3'giene der Schule, in Von Pettenkofer 
iind Ziemssen's Handb. d. Hygiene, II, Th. 2 Abth. — Reuss, Schulbank- 
frage, in Kealencyclopaedie d. ges. Heilk., Bd. XII. — H. Cohn, Schul- 
kinderangen, ibid, — C. J. Lundy, School H^-giene, Public Health, voL 
ix. — Rohe, The Necessit}^ of the Sanitary Supervision of Schools, Journ. 
Am. Med. Ass'n, Dec. 28, 1889.] 



CHAPTER IX. 

Industrial Hygiene. 

One of the most interesting chapters in the study of hygiene 
is that which treats of the relations of occupations to health and 
life. While it is unquestionable that certain occupations are 
intrinsically dangerous to health, there can be no doubt that in 
many instances incidental conditions not necessarily connected 
with the occupation are factors in the production of disease. 
Such factors are bad ventilation and other insanitary surround- 
ings, as well as in many cases want of sufficient or proper 
food. 

Occupations induce disease by compelling the workmen to 
inhale irritating, poisonous, or offensive gases, vapors, or dust ; 
or by causing the absorption through the skin or mucous mem- 
branes of irritating or poisonous substances. Changes of tem- 
perature, as exposure to great heat or cold, produce diseases 
which are, in some instances, characteristic. In another class 
of cases the excessive use of certain organs, as the nervous 
system, the eyes, the vocal organs, or various groups of muscles, 
produce characteristic morbid effects. Again, a constrained 
attitude while at work, a sedentary life, or occupations involving 
exposure to mechanical violence are recognized sources of dis- 
ease and death. 

The following table gives the mortality and average age at 
death of all decedents over 20 years of age whose occupation 
was specified, in the State of Massachusetts, for thirty-one 
years and eight months. The total number of decedents was 
144,954 ; the average age at death, 50.90 years. Subdivided 
into classes and individual occupations, the results are as 
follow : — 

(207) 



208 



TEXT-BOOK OF HYGIENE. 



Table XX. 

Occupations of Persons whose Occupations were specified, and whose Deaths were 
registered in Massachusetts during a period of thirty-one years and eight 
months, ending with December 31, 1874. ^ 



Occupations. 



Class I. Cultivators of 
the Earth: Farmers 
Gardeners, etc. . . 

Class II. Active Me 

chanics Abroad . . 
Brick-makers . . . 
Carpenters and Joiners 
Caulkers and Gravers 

Masons 

Millwrights 

Riggers 

Sliip-carpenters . . . 

Slaters 

Stone-cutters 

Tanners 

Class III. Active Me- 
chanics in Shops . . 

Bakers 

Blacksmiths 

Brewers 

Cabinet-makers . . . 

Calico-printers .... 

Card-makers 

Carriage - makers and 
Trimmers 

Chair-makers . . . . 

Clothiers 

Confectioners .... 

Cooks 

Coopers 

Coppersmiths .... 

Curriers 

Cutlers 

Distillers 

Dyers 

Founders 

Furnace-men .... 

Glass-blowers .... 

Gunsmiths 

Hatters 

Leather-dressers . . . 

Machinists 

Millers 

Musical-Inst. mkrs. . 



Number 

of 
Persons. 



31,832 



10,893 
106 

6,150 
180 

1,662 

118 

161 

873 

81 

1,025 
537 



16,576 

471 

2,402 

28 

781 

9 

39 

276 
138 

84 

85 
112 
927 
101 
366 
131 

27 
143 
361 
133 
132 
250 
356 
179 
2,097 
278 

33 



Average 
Age at 
Death. 



65.29 



5619 
46.85 
53 33 
58.59 
50.33 
59.14 
52 25 
58 53 
40.99 
40.90 
50.36 



47.57 
47.04 
53.26 
47.11 
48.84 
52.11 
48.23 

48.21 
41.77 
56.50 
44.11 
40.82 
59.22 
45.89 
41.50 
39.21 
56.85 
45.17 
42.51 
43.42 
37.88 
48.86 
54.67 
47.23 
41.67 
57.14 
46.73 



Occupations. 



Nail-makers . . , . 
Pail- and Tub- makers 

Painters 

Paper-makers . . . 
Piano-forte-makers 

Plumbers 

Potters 

Pump- and Block 

makers . . 
Reed-makers 
Rope-makers 
Tallow-chandlers 
Tinsmiths 
Trunk-makers 
Upholsterers 
Weavers . . 
Wheelwrights 
Wood-turners 
Mechanics (not sped 

fled) 

Class IV. Inactive 
Mechanics in Shops 

Barbers 

Basket-makers . . . 

Book-binders . . . . 

Brush -makers . . . 

Carvers . . . . . 

Cigar-makers . . 

Clock - and watch- 
makers 

Comb-makers .... 

Engravers 

Glass-cutters . . . . 

Harness-makers . . . 

Jewelers 

Operatives 

Printers 

Sail -makers 

Shoe- cutters . . . . 

Shoe-makers .... 

Silver or Gold smiths 

Tailors 

Tobacconists .... 

Whip-makers .... 

Wool-sorters .... 



Number 

of 
Persons, 



174 
5 

1,850 

288 

111 

131 

40 



9 

248 

67 

375 

48 

124 

480 

507 

76 

J, 015 



17,233 

403 
70 

150 
53 
90 

154 

100 
134 
124 

76 
423 
468 
2.138 
717 
217 
362 
9,772 

92 
1,393 

43 

99 
155 



» Thirty-third Registration Report of Massachusetts, p. cvi et seq. 



INDUSTRIAL HYGIENE. 



209 



Table XX (continued). 



Occupations, 



Class V. Laborers (no 
special trades) . . . 

Laborers 

Servants 

Stevedores 

TVatchmen 

Workmen in Powder- 
mills 

Class Y I . Factors 

Laboring Abroad, etc. 

Baggage-masters . . . 

Brakemen 

Butchers 

Chimney-sweeps . . . 

Drivers 

Drovers 

Engin'rs and Firemen 
Expressmen ..... 

Ferry^ien 

Ligirthouse-keepers 

Peddlers . 

Sextons 

Soldiers 

Stablers 

Teamsters ...... 

"Weighers and Gangers 
Wharfingers 

Class YII. Employed 
on the Ocean .... 

Fishermen 

Marines 

Naval Officers .... 

Pilots 

Seamen 

Class VIII. 3ferch'ts, 
Financ'rs, Ag'ts, etc. 

Agents 

Bankers 

Bank Officers .... 

Boarding-House kprs. 

Book-sellers 

Brokers 

Clerks and Book-kprs. 

Druggists and Apoth- 
ecaries 



Number Average 
of I Age at 
Persons, j Death. 



28,058 
27,383 

389 
76 

193 

18 



7,035 

37 

246 

537 

4 

327 

17 

567 

216 

9 

10 

417 

81 

2,885 

354 

1,282 

24 

9.0. 



,844 

433 

4 

58 



,267 



15,977 
376 

49 

151 

7o 

73 

198 

3,435 

255 



47.41 
47.49 
40.10 
52. C 9 
50 0a 

39.67 

36.29 
34.08 
26.44 
50.19 
34.50 
18 8S 
49.29 
38.77 
41.30 
53.78 
60.40 
45.18 
59 94 
28 87 
42.54 
40.35 
60.67 
50.00 



46.44 
42.82 
41.25 
50.00 
60.38 
46.45 



48.95 

46.76 
57 61 
55.14 
47.96 
53 Oo 
49 58 
35.93 

42.37 



OCCrPATIONS. 



Gentlemen 

Grocers 

Innkeepers 

Manufacturers . . . 

Merchants 

Xews-dlrs. and Car'rs 

K. R. Agents or Con- 
ductors 

Saloon- and Restau- 
rant- keepers . . . 

Stove-dealers . . . . 

Telegraphers . . . . 

Traders 

Class IX . Profes- 
sional Men . . . . 

Architects 

Artists 

Civil Engineers . . . 

Clergymen 

Comedians 

Dentists 

Editors and Reprtrs. 

Judges and Justices . 

Lawyers 

Musicians 

Photographers . . . 

Physicians ..... 

Pi'ofessors 

Public Officers . . . 

Sheriffs, Constables, 
and Policemen . . 

Students 

Surveyors 

Teachers 

Class X. Females . 

Domestics 

Dress-makers .... 

Milliners 

Xurses 

Operatives 

Seamstresses .... 
Shoe-binders .... 
Straw-workers . . . 

Tailoresses 

Teachers 

Telegraphers .... 



Number Average 

of Age at 

Persons. Death. 



•1,512 

517 

467 

1,375 

3,927 

27 

318 

299 

12 
5 

2,908 

5,175 

29 

186 

117 

965 

32 

114 

87 

18 

676 

266 

10 

1,166 

45 

437 

158 

288 

86 

495 

o,343 

1,037 

259 

136 

116 

703 

289 

48 

73 

233 

442 



€8 42 
47.59 
50.04 
51.23 

54.17 
41.23 

39.85 

40.90 

45.25 

28.80 
48.08 

50.81 
47.07 
44.18 
42.32 
58 57 
37 31 
41.61 
46.68 
64.11 
56.45 
41.59 
36.80 
54.99 
55.93 
55.37 

53.76 
23.23 
51.44 
41.79 

39.13 

46 64 
43.36 
39.42 
61.06 
27.82 
46.50 
43.12 
34 83 
47.49 
31.27 
24.43 



The above table cannot be absolutely relied upon for several 
reasons, the prmcipal of which is that the table is incomplete. 
Many of the occupations are merely temporary, and persons are 



u 



210 TEXT-BOOK OF HYGIENE. 

constantly shifting from the pursuit of one calUng to another. 
Judges and lawyers, for example, should be included under one 
heading, while the class " students " should be excluded alto- 
gether. The table shows, however, very clearly, the relations of 
certain occupations to longevity. It is seen, for example, that 
agriculturists have the greatest expectation of life. Next to 
these come mechanics engaged out-of-doors. Professional men 
come next, and of these clergymen and members of the bar have 
the first and second places, respectively. The expectation of 
life of physicians is above the average, being nearly 55 years. 
Mechanics engaged in active work in-doors may expect to live 
3.70 years longer than those whose occupation requires them to 
retain a more or less constant position. 

Occupations which are accompanied by the formation of 
much dust, either inorganic or organic, are especially unfavor- 
able. They usually produce diseases of the respiratory organs, 
which may eventuate in phthisis. In the table it is seen 
that the average age at death of stone-cutters was 40.90 ; of 
cotton-factory operatives — male 39.16, female 27.82;^ of cigar- 
makers, 38.36 ; and of cutlers, 39.21 years. The figures more 
or less closely approximate the conditions which have been 
shown to exist in England and on the Continent of Europe. In 
Shefiield, the workmen who grind and polish the cutlery, called 
" dry grinders," are said to sufier from a characteristic pulmo- 
nary afiection termed "grinders' asthma" (emphysema) in the 
proportion of 69 per cent, of the whole number employed. The 
average duration of life of the needle-grinders of Derbyshire 
is 30.66 years. Among the cutlery-grinders of Solingen, in 
Rhenish Prussia, Oldendorfi* found 29 per cent, sufiering from 
pulmonary afiections, while the average age at death of the 
" dry grinders " was 40.7 years. 

These figures must be accepted with much reserve. While it is probable that the 
average age at death among women engaged in different occupations is less than that of men 
engaged in the same occupations, the figures in Table XX, Class X, cannot be used as a basis of 
comparison. So many women are annually withdrawn from the various occupations by mar- 
riage, which places them under different conditions, that the statistics of the occupations of 
women in the table are untrustworthy. 



OCCUPATIOXS PREJUDICIAL TO HEALTH. 211 

OCCUPATIOXS PREJUDICIAL TO HEALTH. 

The diseases of occupations may conveniently be divided 
into the following classes : — 

1. Diseases due to the inhalation of irritating or poisonous 
gases and vapors. 

2. Diseases due to the inhalation of irritating or poisonous 
dust. 

3. Diseases due to the absoi-ption or local action of irritating 
or poisonous substances. 

•4. Diseases due to exposure to elevated or variable temper- 
ature or atmospheric pressure. 

5. Diseases due to excessive use of certain organs. 

6. Diseases due to a constrained attitude and sedentary life. 

7. Diseases from exposure to mechanical violence. 

I. — DISEASES DUE TO THE IXHALATIOX OF IRRITATING OR POISONOUS 

GASES OR VAPORS. 

SulpJiurous-add gas is used in various trades as a bleach- 
ing agent. In the manufacture of straw hats and in the drying 
or " processing " of hops this agent is extensively employed, 
and the people engaged m these industries frequently suffer 
from respiratory and digestive disorders. These are, however, 
rarely serious. If free access of air is allowed, the dansfers to 
health in the above employments are ver}' slight. 

Nitric-acid fumes may be dangerous to health when in- 
haled in a concentrated form, but very few cases are on record 
where any positively deleterious influence can be traced to this 
agent. 

HydrocJiloric-acid fumes may prove deleterious to the work- 
men in soda manufactories, w^here the fumes are disengaged 
during the so-called " sulphate process." But the danger is 
probably slight. On the other hand, attention has recently been 
called to a peculiar effect of hydrochloric-acid fumes upon the 
workmen in fruit-canning establishments. The men who seal 
or '• cap " the cans after being filled are the ones affected. The 



212 TEXT-BOOK OF HYGIENE. 

lesion has been described by Dr. W. Stump Forwood, who says 
concerning it : " The constant inhalation of the fumes of muri 
atic acid, associated as they are with the lead solder, which the 
busy " capper " neglects to protect himself against, soon pro-l 
duces inflammation of the mucous membrane of the nose, which 
finally results in ulceration. With some patients, after the 
removal of the cause and the application of proper treatment, 
recovery takes place after two or three months ; but with those 
who have a scrofulous taint in their constitutions this ulceration 
is exceedingly intractable, and, in spite of all treatment, proceeds 
for months and even years, until the septum is finally perforated. 
And, strange to say, it is the common experience of those who 
have suflered that, as soon as perforation takes place, all the 
soreness and consequent annoyance disappears and the patient 
recovers, with, of course, a permanent opening in the nasal 
septum."^ Dr. Forwood adds that anointing the nose, both 
within and without, several times a day, and avoidance of the 
acid fumes as much as possible, will prevent the peculiar afiection. 

Ammonia rarely causes disturbances of health in work- 
men brought into contact with it. When present in the air in 
large proportion it may give rise to serious symptoms. As it is 
often used to prevent the poisonous eff'ects of mercury {q. v.), care 
should be taken that the proportion of the vapor in the air of 
the work-room should not exceed 5 per cent. 

Chlorine gas is very deleterious in its effects upon the work- 
men brought in contact with it in the various industries in which 
it is employed. Nearly one-half of the workmen engaged in th 
manufacture of chlorinated lime and in bleaching become affected. 

The respiratory organs are principally attacked. Pneu- 
monia is exceptionally frequent. If an affected individual is 
predisposed to consumption the latter disease is soon lighted up, 
and quickly proves fatal. The effect of the inhalation of con- 
centrated chlorine is thus graphically described by Hirt ^ : " The 

iPhila, Med. and Surgical Reporter, June 30, 1883. 

« Von Pettenkofer und Ziemssen's Handbuclider Hygiene, etc., 11 Th., 4 Abth., p. 30. 



3 



I 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 213 

workman suffers from violent cough and extreme dyspnoea. In 
spite of the aid of the auxihary respiratory muscles, the entrance 
of air to the lungs is insufficient, and the widely-opened eyes, 
the pale-bluish color, and the cold perspiration plainly show the 
mortal agony of the patient. With this the pulse is small, the 
temperature decreased. Soon after removal from the impreg- 
nated atmosphere these phenomena disappear, and a few hours 
later the workman is found enveloped in chlorine and hydro- 
chloric-acid vapors in his accustomed place in the factory. The 
attacks seem to be but rarely fatal." 

The constant inhalation of an atmosphere strongly impreg- 
nated with chlorine produces a cachectic appearance, bronchial 
catarrh, loss of the sense of smell, and a prematurely aged appear- 
ance. When this stage of chronic chlorine poisoning has been 
reached complete health can rarely be re-established, even if 
the patients be entirely removed from the irritating atmosphere. 

Carhon monoxide is often present in the air of gas-works, 
iron smelting-works, and coke or charcoal furnaces. The work- 
men engaged in these industries often suffer with diseases of the 
respiratory organs, digestive disturbances, and general debility. 
Acute poisoning from carbon monoxide is relatively frequent, as 
already pointed out.-^ The prominent symptoms are at first vio- 
lent headache, dizziness, and roaring in the ears. These symp- 
toms are followed by great depression of muscular power, nausea, 
and vomiting. The vomited matters sometimes gain entrance 
into the trachea, and may thus produce strangulation. Uncon- 
sciousness, convulsions, and asphyxia rapidly succeed. Paral- 
yses of the sphincters and of groups of other muscles are often 
present. The pulse is at first somewhat increased, but soon 
becomes slower. The respiration is slow and stertorous, and the 
temperature falls from 2.5° to 3° C. (3° to 4° F.). Glycosuria 
often occurs. If death does not occur in the attack, the patient fre- 
quently suffers from great depression, both physical and mental; 
loss of appetite, constipation, and various paretic conditions. 

> See Chapter I, p. 29. 



214 TEXT-BOOK OF HYGIENE. 

The slow or chronic form of poisonmg by carbon monoxide 
is characterized by headache, dizziness, slow pulse and respira- 
tion, nausea, and sometimes vomiting and purging. Loss of 
memory and diminution of mental activity are also said to be 
effects of the continued inhalation of air charged with carbon 
monoxide. 

Carbon dioxide is found as one of the constituents of the 
"choke-damp" in mines. There is reason to believe that this 
is often the source of ill health and death in miners, even where 
the symptoms of acute carbon-dioxide poisoning are not present. 
Hon. Andrew E,oy^ says that "it is more insidious than direct in 
its operations, gradually undermining the constitution and kill- 
ing the men by inches." Difficulty of respiration and w^eakness 
are the only symptoms calling attention to the pernicious effects 
of the gas. Where, however, the proportion of carbon dioxide 
is large, acute poisoning occurs. This is manifested by the 
following symptoms : Loss of consciousness and of the power of 
voluntary motion. Li some cases there are convulsions ; in 
others the above symptoms are preceded by difficult respiration, 
headache, depression, drowsiness, or psychical excitement. Re- 
covery usually soon follows after removing the patient into a 
purer atmosphere. 

Vintners, distillers, brewers, and yeast-makers are said to 
suffer from the effects of carbon dioxide occasionally, but serious 
results from this cause are probably very infrequent. I 

It may not be amiss to call attention here to another dan- 
gerous mixture of gases sometimes found in mines, and which 
is occasionally the source of appalling accidents. This is the 
so-called "fire-damp" or light carburetted hydrogen (CH4). 
When this gas is mixed with atmospheric air in the proportion 
of 6 to 10 volumes per cent., the mixture becomes violently 
explosive if ignited. The danger does not cease with the explo- 
sion, however, for in this act the free oxygen present is consumed 



* Third Annual Report State Mine Inspector of Ohio. Quoted in Buck's Hygiene and 
Public Health, vol. ii, p. 243. 



i 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 215 

ill the formation of carbon dioxide, and the workmen then die 
asphyxiated, or from the effects of '' choke-damp." The dangers 
from " fire-damp " can be largely averted by thorough ventilation 
and by the use of the safety-lamp of Sir Humphry Davy, which 
gives warning of the presence of the gas and permits the work- 
men to escape before the explosion takes place. 

Sulphur etted hydrogen^ when present in the air in large 
proportion, — as, for example, in privy-vaults, cess-pools, and 
sewers, — may produce serious or fatal poisoning. Formerly, 
when vaults were cleaned in the primitive way, these accidents 
were frequent; but at the present day, owing to improved 
methods of removing excreta, they are comparatively rare. The 
precautions advised in a preceding chapter^ should be borne in 
mind when it is necessary for workmen to enter such places. 

The gases resulting from t\\e putrid decomposition of organic 
substances^ such as are found in tanneries, glue- and soap- works, 
and similar industries, are popularly believed to give rise to 
various diseases. There are no observations on record, however, 
to show that such is the case. As a matter of fact, the workmen 
engaged in the industries mentioned, seem to be exceptionally 
healthy, and to resist to a considerable degree the ravages of 
phthisis and epidemic diseases. 

Bisulphide of carbon is used in the arts principally in the 
process of vulcanizing India rubber, and for extracting oils from 
seeds and fatty bodies. The constant inhalation of the vapor 
of bisulphide of carbon produces a train of s}'mptoms to which 
attention was first attracted by Delpech in 1856. The symp- 
toms have been observed frequently since that time. The follow- 
ing account is from Hirt ^: — 

" Some days, or even weeks or months, after beginning this 
occupation, the workmen complain of a dull headache, becoming 
more severe toward evening. This symptom is soon followed by 
joint-pains, formication, and itching on various parts of the body. 
A more or less troublesome cough is present, but is not accom- 

» Chapter I, p. 37. « Op. cit., p. 66. 



216 TEXT-BOOK OF HYGIENE. 

panied by any characteristic sputa. The respiration is regular, 
the pulse somewhat increased in frequency. During this time 
certain individuals exhibit a marked exaltation of their intel- 
lectual powers; they talk more than formerly, and show an 
interest in matters in which they at other times show no concern. 
There is, however, very rarely distinct mental disease. The 
sexual desires are increased in both sexes, menstruation becomes 
irregular, and the urine possesses a faint odor of bisulphide of 
carbon. In this manner several weeks or months pass away. 
Very gradually the psychical exaltation disappears, and a pro- 
found depression, melancholy, and discouragement succeeds, 
coupled with which is often loss of memory. Vision and hear- 
ing become less acute, and the sexual activity is completely 
destroyed. Anaesthetic spots appear on various parts of the body, 
and numbness of the fingers prevents the workman from perform- 
ing any fine work." 

The disease never proves fatal, but the normal condition 
of the individual is rarely re-established when the disorder has 
advanced to the extreme stages mentioned. 

Iodine and hromine vapors, when inhaled by workmen en- 
gaged in their preparation, produce symptoms of poisoning 
which are sometimes very serious. Acute iodic intoxication 
consists in severe laryngeal irritation, headache, conjunctivitis, 
and nasal catarrh. Occasionally there is temporary loss of con- 
sciousness. Chronic iodic cachexia is often found among the 
workmen. In certain cases atrophy of the testicles and gradual 
disappearance of sexual power has been observed. In the manu- 
facture of bromine, a form of bronchial asthma has been 
observed among those engaged in the establishment. No 
symptoms corresponding to those of chronic iodism have been 
observed among the w^orkmen in bromine. 

The inhalation of the vapors of turpentine produces, in a 
considerable number of those constantly exposed to them, dis- 
eases of the respiratory organs, beginning with cough and, at 
times, resulting in consumption. In other cases derangement 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 217 

of the digestive organs, strangury, and, in a few cases, bloody 
urine have been observed. Nervous disturbances are rare after 
the inhalation of turpentine, and are limited to headache, roar- 
ing in the ears, or flashes of light before the eyes. 

Petroleum vapoi\ when inhaled in a concentrated state, pro- 
duces symptoms similar to those of anaesthetics. When exposed 
for a long time to diluted petroleum vapor, workmen sometimes 
suffer from chronic pulmonary catarrhs or from nervous de- 
rangements. Among the latter are disturbances of mental 
activity, loss of memory, giddiness, and headache. These symp- 
toms are, however, rare. More frequent are pustular or furuncu- 
lar affections of the skin, which are due probably to the direct 
irritant effect of the vapor. 

Lead poisoning is one of the most characteristic diseases of 
artisans. It attacks workmen engaged in the roasting and smelt- 
ing of lead ores ; in the manufacture of white and red lead and 
of lead acetate and chromate ; in type-making, in painting, and, 
in short, in all occupations in Avliich the workman is compelled 
to inhale the vapor or dust of lead, or in which it is conveyed 
in some manner to the digestive organs. It is believed also that 
it can be absorbed by the skin and produce its poisonous effects 
upon the economy. The average duration of life in the roast- 
ing and smelting furnaces is 41 years ; of painters, as shown by 
Table XX, 45.07 years. Of the latter 75 per cent, are attacked 
by one of the forms of lead poisoning, colic being most frequent. 
In the manufacture of white lead more than half of the work- 
men suffer from lead poisoning during the first year, lead colic 
being present in 60 per cent, of all the cases. 

In most sugar-of-lead manufactories 60 per cent, of all 
the operatives constantly suffer from some form of lead 

ming. 

Poisoning has also been observed in workmen engaged in 
the manufacture of various pigments of which the acetate of 
lead is the base {e.g.^ lead chromates). Among type-founders 
the symptoms of lead poisoning are not very rare, and even 



218 TEXT-BOOK OF HYGIENE. 

compositors sometimes suffer from lead poisoning. In the latter 
case the lead must be absorbed through the skin in order to 
produce its effects. 

The various forms in which lead poisoning affects the indi- 
vidual are the lead cachexia, manifested by loss of weight, dis- 
coloration of the skin, the characteristic blue line along the 
gums, diminution of the salivary secretion, a sweetish taste, and 
offensive odor of the breath ; then lead colic, the features of 
which are well known ; lead paralysis, the characteristic " wrist- 
drop," which requires prompt and intelligent treatment, other- 
wise permanent atrophy of the affected muscles often takes place. 
Among other nervous manifestations of the poison is a painful 
affection of the lower extremities, attacking joints and flexor 
muscles, and remittent in character. At times anaesthesia of the 
skin of the head and neck is present. In rare cases serious 
mental derangement occurs. Other grave nervous lesions, such 
as the so-called saturnine hemiplegia and tabes, are happily 
extremely rare among the workmen in the metal at the present 
day. 

Mercurial poisoning is frequent among the artisans who 
work in the metal. The smelters of the ore suffer severely and 
in a large proportion of the entire number employed. Their 
average age at death is 45 years. Mirror-makers suffer most 
severely of all the artisans who come in contact with the vapors 
of the metal. It is beyond question that the confinement in 
badly- ventilated work-rooms is largely responsible for the poi- 
sonous effects of the metal upon this class. The special forms 
in which the poisonous effects are manifested in mirror-makers 
are salivation, mercurial tremor, and nervous erethism, but, in 
addition, a very large proportion suffer from pulmonary con- 
sumption. It is stated tliat 71 per cent, of the total deaths 
among mirror-makers (those who coat the glass with the mer- 
curial alloy) are from phthisis. 

Among women the symptoms are aggravated, and abortion 
frequently occurs. Of the children of women suffering from 



DISEASES DUE TO INHALATION OF GASES OR VAPORS. 219 

mercurial poisoning born living at term, 65 per cent, die within 
the first year. 

In the Almaden quicksilver mines in Spain a considerable 
proportion of the workmen suffer from the milder symptoms of 
mercurial intoxication (gingivitis, salivation, or dryness of the 
mouth). The more severe manifestations (tremor, convulsions, 
contractures, violent muscular pains, paralysis, cachexia) are 
much less frequent, and latterly not so severe as they were 
formerly. 

Fire-gilders, fulminate-makers, and physical instrument- 
makers not infrequently suffer from the deleterious effects of 
inhaling the vapor of mercury. Hatters are also liable, to a 
considerable extent, to the poisonous effects of the metal.^ 

It has been found that upon sprinkling the floor of the 
work-room of mirror-makers with aqua ammonia, so as to im- 
pregnate the atmosphere with ammonia, the bad effects of mer- 
cury on the system are markedly diminished. Care must be 
taken, however, not to use the ammonia to excess, otherwise the 
diseases caused by this agent may attack the workmen. 

Zinc or copper vapors^ or possibly a combination of the 
two, given off from the brass, which is an alloy of these metals, 
produces a peculiar train of symptoms known as ''brass- 
founders' ague," The symptoms are described by Hirt, who 
has suffered from two attacks of the affection himself, as fol- 
lows ^ : "A few hours after attending the process of brass- 
casting, one notices a peculiar, uncomfortable sensation over the 
whole body. More or less severe pains in the back and gen- 
eral lassitude cause a discontinuance of the ordinary occupa- 
tion. While the pains appear now here, now there, and are 
extremely annoying, no changes in the pulse or respiration are 
noticeable. In a short time, however, usually after the patient 
has taken to the bed, chilliness comes on, which soon increases 
to a decided rigor, lasting fifteen minutes or longer. In the 

1 Hatting as Affecting the Health of Operatives, L. Dennis, Report New Jersey State 
Board of Health, 1879 ; Connecticut State Board of Health, 1883. 
a Op. cit., p. 122. 



220 TEXT-BOOK OF HYGIENE. 

course of an hour or less the pulse now reaches a rapidity of 
100 to 120 beats per minute. A tormenting cough, combined 
with a feeling of soreness in the chest, comes on. In conse- 
quence of the repeated acts of coughing, the increasing frontal 
headache produces exceeding discomfort. Soon, however, usu- 
ally after a few hours, the height of the attack is reached ; free 
perspiration indicates the stage of defervescence, and during the 
gradual diminution of the symptoms the patient falls into a 
deep sleep, lasting several hours. On awakening, a slight 
headache and lassitude only remain as reminders of the 
attack." 

It is said that about 75 per cent, of the workmen in brass- 
foundries are attacked by this aifection ; the attack is liable to 
be repeated at every exposure. 

A chronic form of poisoning is said to occur among zinc- 
smelters after following their occupation for ten to twelve years. 
It consists of hy perse sthesia, formication, and burning of the 
skin of the lower extremities, soon followed by alteration in the 
temperature and tactile sensation, and diminution of the mus- 
cular sense. Paresis of the lower extremities sometimes comes 
on. The disease has not yet been sufficiently investigated. 

Aniline vcifpor is exceedingly poisonous when inhaled in a 
concentrated state. Hirt describes an acute form which usually 
results fatally: "The workman falls suddenly to the ground; 
the skin is cold, pale ; the face is cyanotic, the breath has the 
odor of aniline, the respiration is slowed, and the pulse increased. 
The sensation, diminished from the beginning of the attack, 
gradually entirely disappears, and death follows in a state of deep 
coma."^ There is a milder form which comes on after several 
days of exposure. It is characterized by laryngeal irritation, 
diminution of appetite, headache, giddiness, great weakness, 
and depression. The pulse is rapid, small, and irregular. 
Respiration is little altered. There is decrease of sensibility of the 
skin. Convulsions may occur, but are usually of short duration. 

1 Op. cU., p. 127. 



DISEASES DUE TO INHALATION OF DUST. 221 

The chronic form of anihne poisoning is characterized by 
three sets of symptoms : those affecting the central nervous 
system, the digestive tract, and the skin. Among the first are 
lassitude, headache, roaring in the ears, and disturbances of 
sensation and motion of greater or less degree. 

The digestive derangements consist in eructations, nausea, 
and vomiting. 

The cutaneous lesions are eczematous or pustular eruptions, 
and sometimes round, sharply-circumscribed ulcers Avith callous 
borders. 

There is no trustworthy evidence that in the manufacture 
of aniline colors poisonous symptoms are produced in the 
workmen. 

II. — DISEASES DUE TO THE INHALATION OF IRRITATING OR 
POISONOUS DUST. 

The inhalation of air containing particles of organic or 
inorganic matter has long been accepted as a cause of certain 
special diseases of artisans. The diseases so caused are usually 
limited to the pulmonary organs, and consist of acute and 
chronic catarrh, emphysema of the lungs, pneumonia, interstitial 
inflammation of the lungs, — the so-called fibroid phthisis or pul- 
monary cirrhosis. 

Coal'cliLst is inhaled by coal-miners, charcoal-burners, coal- 
handlers, firemen, chimney-sweeps, foundry-men, lead-pencil 
makers, etc. Chronic bronchial catarrhs are most frequent, 
while phthisis and emphysema are almost absent from the list 
of diseases afi'ecting these workmen. Dr. W. B. Canfield has 
reported an interesting case of pneumonoconiosis in which there 
was coincident bacillary phthisis.^ The table on page 208 shows 
that the expectation of life of foundry-men, furnace-men, fire- 
men, and chimney-sweeps is much below the average. 

Metallic dust is inhaled by blacksmiths, nailers, cutlers, lock- 
smiths, file-cutters, cutlery- and needle- polishers, etc. While 

» Trans. Med. and Chir. Fac, Md., 1889. 



222 TEXT-BOOK OF HYGIENE. 

in this class of workmen cases of bronchitis and pneumonia 
are relatively frequent, much the largest proportion suffer from 
phthisis. A table compiled by Hirt shows that out of the total 
number of sick in the different classes of workmen the cases of 

phthisis were : — 

62.2 per cent, for file-cutters, 
69.6 " " needle-polishers, 

40.4 " " grinders, 

12.2 " " nailers. 

The Massachusetts table gives the average duration of life 
for blacksmiths at 53.26 years, of nail-makers at 41.49 years, 
and of cutlers at 39.21 years. The needle-polishers at Sheffield, 
as already stated (page 210), have only an average duration of 
life of 30.66 years. In this work and that of grinding knives, 
scissors, and similar articles, the metallic dust is mixed with 
mineral dust (particles of silica from the grindstone). This 
mixture seems to be much more deleterious than metallic dust 
alone, as shown by the shorter average duration of life and the 
enormous percentage of cases of consumption. 

Mineral dust is inhaled by the workmen in a large number 
of different industries. The grinders in the ground-glass factories 
suffer most severely. Hirt found the average duration of life in 
grinders who began this occupation after their 25th year to be 
42.50 years, while in those who began at the age of 15 the 
average duration was 30 years. 

Millstone cutting is also a very dangerous occupation. Pea- 
cock^ gives the average age of these workmen at 24.1 years. 
Stone-cutters generally suffer frequently from phthisis, probably 
largely in consequence of the constant inhalation of the mineral 
dust produced during their work. The Massachusetts table gives 
the average age at death of these workmen at 40.90 years, 
while Hirt's table gives a much lower age, namely 36.3 years. 
Potters and porcelain-makers are exposed to similar dangers 
from their occupation, but to a much less degree. The table on 

1 QuotedbyMerkel, invonPettenkofer und Ziemssen's Handbucli der Hygiene, II Th., 
4Abtli., p. 197. 



DISEASES DUE TO INHALATION OF DUST. 223 

page 208 gives tlie average age at death at 56.67 years, — rather 
a high average. 

Slaters and workmen in slate-quarries suffer in a large pro- 
portion of cases from chronic pneumonia, and die at a compara- 
tively early age. 

Masons and carpenters have an average duration of life of 
50.33 and 53.33 years, respectively. One-third of all the diseases 
from which they suffer affect the respiratory organs. 

Gussenbauer has reported a very interesting series of cases 
of a peculiar inflammatory affection of the diaphyses of the long 
bones in the artisans who are engaged in the manufacture of 
pearl buttons. 

Gem-finishers are exposed not only to the inhalation of 
dust, but to poisonous gases (carbon monoxide) and vapors 
(lead). The proportion of sickness among tliem is veiy high. 

Vegetahle Dust. — The workmen compelled to inhale vege- 
table dust are those who work in tobacco, cotton-operatives, 
flax-dressers, paper-makers, weavers, wood-turners, millers, and 
laborers in grain-elevators. 

Workmen in tobacco usually suffer, within a few weeks 
after beginning work, from a nasal, conjunctival, and bronchial 
catarrh, which soon passes off, as the mucous membranes seem 
to become accustomed to the irritation. Nausea is also frequent 
at first, due probably to the absorption of small quantities of 
nicotine. Females exposed to tobacco-dust usually suffer from 
digestive and nervous troubles. They are also said to abort 
frequently. 

Dr. R. S. Tracy ,^ as a result of his observations among 
cigar-makers in New York, states that the fecundity of these 
people is much less than the average. Three hundred and 
twenty-five families visited had only 4:6d children, an average 
of 1.43 to each family. Dr. Tracy is inclined to attribute this 
to the frequent abortions that occur among the females exposed to 
the inhalation of tobacco-dust. According to the Massachusetts 

» Buck's Hygiene and Public Health, vol. ii, p. 62. 



224 TEXT-BOOK OF HYGIENE. 

table, cigar-making is an unfavorable occupation, the average 
age at death being 38.36 years. 

Cotton-operatives, flax-dressers, weavers, and workmen in 
paper-mills are subject to various diseases of the respiratory- 
organs. Coetsem, as long ago as 1836, described a peculiar 
pulmonary aflection among cotton-operatives, which he termed 
pneumonle coionneuse. The observation does not seem to have 
been verified by others ; at all events, the author is unable to 
find any other record of a similar afi'ection in the literature of 
the subject. Among weavers the mortality from phthisis is 
comparatively high. Among paper-makers Hirt found an 
average duration of life of 37.6 years. The people who sort 
rags are liable to a fatal infectious disease, "rag-sorters' disease" 
(Hadernkrankheit ^), which resembles in all respects, and is prob- 
ably nothing less than, anthrax. No cases have been reported 
in this country, but, as the importation of rags from abroad is 
carried on to a considerable extent, no apology is believed to be 
necessary for calling attention to it. The " wool-sorters' disease," 
to which attention has recently been called in England, is doubt- 
less similar in its nature. 

Millers sufi*er in a large proportion of cases from pulmonary 
affections, especially bronchial catarrh and pneumonia. Accord- 
ing to Hirt, 20.3 per cent, of all tlie diseases of these workmen 
are pneumonias, 9.3 per cent, bronchial catarrhs, 10.9 per cent, 
phthisis, and 1.9 per cent, emphysema. The average duration 
of life is 45.1 years. The Massachusetts table gives 57.14 years, 
— a very much more favorable exhibit. 

The laborers in grain-elevators are compelled to inhale a 
very irritating dust, which causes acute and chronic catarrhs of 
the respiratory organs. Dr. T. B. Evans, of Baltimore, has 
reported a series of cases of catarrhal pneumonia in these work- 
men, which were characterized by some very peculiar features. 
Brush-making, according to the statistics of Hirt, is a very dan- 
gerous occupation. Nearly one-half of the deaths among brush- 

1 See article by Soyka, Realencyclopaedle d, ges. Heilk, Bd. VI, p. 165. 



DISEASES DUE TO POISONOUS SUBSTANCES. 225 

makers are from phthisis, due, in great measure, to the inhalation 
of the sharp fragments of bristles produced in trimming the 
brushes. In the Massachusetts table the averasre duration of 
life is given at 43.11 years. 

III. — DISEASES DUE TO THE ABSORPTION OR LOCAL ACTION OF 
IRRITATING OR POISONOUS SUBSTANCES. 

Arsenic is used in the manufacture of green pigments and 
for various other purposes in the arts. In the preservation of 
furs and in taxidermy it finds extensive use. In the prepara- 
tion of the pigment known as Paris green the workmen are 
frequently entirely covered by a layer of the poisonous salt. The 
poisonous symptoms occur in consequence of the absorption of 
the poison through the skin or from its local action, and but 
rarely on account of mhalation of vapors or dust in which it is 
contained. The most marked symptoms are chronic gastric 
catarrh, superficial erosions in the mouth, dry tongue, thirst, and 
a burning sensation in the throat. These symptoms may con- 
tinue for months, or even years, and gradually produce a com- 
plete breaking down of nutrition and the vital powers. Violent 
itching skin eruptions of an eczematous character are not infre- 
quent complications of the internal symptoms. 

Lewin has described a localized pigmentation of the skin 
in workmen (engravers) in silver. The left hand is especially 
affected. The occurrence of the affection is explained by the 
numerous slight injuries of the hands by the graver's tools and 
the local absorption and decomposition of the silver. 

Pliospliorus produces two classes of effects in persons sub- 
jected to its influence. The milder effects are produced by the 
inhalation of the fumes of the substance, and are limited to 
digestive disturbances and diseases of the pulmonary organs. 
The severer symptoms are only observed among the employes 
in match-factories, and are due to the local action of the phos- 
phorus upon the tissues affected. 

The characteristic disease produced by phosphorus is a 

15 



226 TEXT-BOOK OF HYGIENE. 

painful periostitis of the lower or upper jaw. The limitation 
of the affection to this locality is believed to be due to the action 
of the phosphorus dissolved in the saliva. The fact that the 
lower jaw, with which the saliva comes more thoroughly in 
contact, is most frequently affected seems to indicate that this 
view is the correct one. The disease begins, on an average, five 
years after the beginning of the employment. Hirt estimates 
the proportion of employes in match-factories attacked at 11 to 
12 per cent. The first symptom of the disease is toothache, 
soon extending to the jaw. The cervical glands swell up ; the 
gums become reddened and spongy ; abscesses form about the 
diseased teeth, from which large quantities of thin, offensive pus 
are discharged. Examination with a sound reveals carious, 
nodulated bone. The cheeks become swollen, erysipelatous, 
and may suppurate and discharge pus externally. 

Hutchinson has reported a case in which the long-continued 
internal administration of phosphorus as a medicine produced 
maxillary necrosis. 

The destruction of the soft tissues continues until resection 
of the jaw is finally undertaken and the disease checked by 
surgical interference, and removal of the patient from the influ- 
ence of the pernicious substance. 

Dr. J. Ewing Mears reports^ 16 cases of phosphorus ne- 
crosis. He concludes " that the antidotal powers of turpentine 
have been established, both in neutralizing the effects of the 
poison upon operatives during their work and also in the treat- 
ment of the early stage of the disease. The disease is to be 
prevented by the adoption of thorough methods of ventilation, 
stringent rules with regard to cleanliness, and the free disen- 
gagement of the vapors of turpentine in all the apartments of 
factories in which the fumes of phosphorus escape." 

In the manufacture of qxdnine a troublesome eczema is 
caused in about 90 per cent, of the employes. It seems to be 
due to emanations given off from the boiling solutions. It 

» Trans. Am. Surg. Association, 1887. 



DISEASES DUE TO ELEVATED OR VARIABLE TEMPERATURE. 227 

begins with intense itching, followed by swelling and the forma- 
tion of vesicles, which soon burst and form crusts. There is 
considerable fever when the swelling is great. It is said that 
blondes are more frequently affected than those of dark com- 
plexion. The disease soon disappears if the work is given up. 

The workmen engaged in the manufacture of bichromate 
of potassium are said to suiFer from an ulceration of the nasal 
mucous membrane very similar to that already described as due 
to the vapors of hydrochloric acid (p. 212). Rapidly spreading, 
deep ulcers are also said to form if the bichromate comes in 
contact with abraded surfaces of the skin. 

The strong alJmJi handled by tanners frequently produces 
fissured eczemas of the hands, which are painful and often diffi- 
cult to cure. 

The workmen in ijetroleum refineries frequently suffer from 
acneiform or furuncular eruptions. 

Among glass-blowers, syphilis is frequently communicated 
by an infected mouth-piece which is used by the men in turn. 

IV. — DISEASES DUE TO EXPOSURE TO ELEVATED OR VARIABLE 
TEMPERATURE OR ATMOSPHERIC PRESSURE. 

Cooks and bakers are exposed almost constantly to a high 
temperature, which produces an unfavorable influence upon 
health and predisposes them to diseases of various kinds. The 
Massachusetts table shows that cooks have a much shorter 
duration of life than bakers, although the statistics of both 
trades are unfavorable. 

The prevailing diseases among cooks and bakers are rheu- 
matism and eczematous eruptions, generally confined to the 
hands, forearms, and face. 

Blacksmiths, founders, and firemen suffer from the intense 

heat to which they are exposed, in addition to the inhalation of 

I coal-dust, as has already been pointed out. The stokers in the 

engine-rooms of steam-ships suffer especially from the excessively 

high temperature to which they are subjected by their occupation. 



228 TEXT-BOOK OF HYGIENE. 

A form of heart-weakness, described by Levick as " fireman's 
heart," is prevalent among them. 

Sailors, farmers, coachmen, car-drivers, and teamsters are 
subjected to stress of weather, changes of temperature, and 
storms. They suffer frequently from rheumatism, acute bron- 
chitis, pneumonia, and Bright's disease. Car-drivers are said 
also to suffer from painful swelling of the feet, varicose veins 
and ulcers, and mild spinal troubles.^ 

Sun-stroke is not confined to any class of artisans, but 
persons who perform very hard labor, especially in a confined 
atmosphere, suffer most frequently. 

The effects of compressed air on workmen in tunnels and 
deep mines has already been referred to.^ The most serious 
symptoms occur not when the individual is subjected to the 
increased pressure, but when the pressure is too rapidly dimin- 
ished. 

V. — DISEASES DUE TO THE EXCESSIVE USE OF CERTAIN ORGANS. 

The prevalent belief that the overuse of the intellectual 
faculties is a frequent cause of mental disease is not borne out 
by facts. Men and women who perform an amount of mental 
work regarded by most persons as excessive have, in spite of 
this, a long duration of life. There are no exact statistics upon 
this subject, but Caspar, half a century ago, made the following 
estimate of the average duration of life among professional men : 
Clergymen live Q^; merchants, 62.4; officials, 61.7 ; lawyers, 
58.9 ; teachers, 56.9, and physicians, 56.8 years. In the table 
on page 209 the figures are somewhat less favorable, although 
corresponding in general with those of Caspar. Hence, it is 
seen that, of professional men, those whose occupation compels 
the exercise of high mental powers have a higher duration of 
life than any other class, except farmers and mechanics engaged 
actively out of doors. Those professional occupations only 
which necessitate a more or less irregular mode of life and 

* A. McL. Hamilton in Report New York Board of Health, p. 444, 1873. 
» Chapter I, p. 12. 



DISEASES DUE TO A SEDENTARY LIFE. 229 

frequent subjection to physical exhaustion and dangers from 
contagious disease, such as the work of physicians and journal- 
ists, make an imfavorable showing in the statistics. The prop- 
osition may be laid down that it is not mental activity^ however 
great, but mental icorry that tends to the abbreviation of life. 

The occupation of a tea-taster is said to produce a peculiar 
nervous condition, manifested in muscular tremblings, etc., 
which compels the individual to give up the work in a few years. 

Persons who test the quality of tobacco, an occupation corre- 
sponding to that of tea-taster, are said to suffer from nervous symp- 
toms, which may include amaurosis and other grave affections. 

Those persons who are compelled to use their eyes con- 
stantly upon minute objects frequently suffer from defective 
vision. So engravers, watch-makers, and seamstresses are hable 
to near-sightedness, amaurosis, and irritation of the conjunctiva. 
PubHc speakers and singers frequently suffer from catarrhal or 
even paretic conditions of the throat, which usually disappear 
on relinquishing the occupation for a time. 

Telegraph operators and copyists suffer from a peculiar 
con^Tilsive affection of the fingers, called " writers' cramp." 
Cigar-makers are also said to suffer from a similar cramp of 
the fingers used in rolling cigars. Performers on wind instru- 
ments are liable to pulmonary emphysema, on account of the 
pressure to which the lungs are frequently subjected. Boiler- 
makers often suffer from deafness, in consequence of their 
constant existence in an atmosphere in a state of continual violent 
vibration. The affection is generally recognized as "boiler- 
makers' deafness." Dr. C. S. Turnbull has reported several 
cases of " mill-operatives' deafness." Its characteristic is an 
inability to hear distinctly except during a noise. 

VI. DISEASES DUE TO A CONSTRAINED ATTITUDE AND 

SEDENTARY LIFE. 

It is probable that the large mortality and morbility rate 
of persons whose occupations keep them confined within doors 



230 TEXT-BOOK OF HYGIENE. 

are due, next to the defective ventilation, to the constrained 
attitude which most of them necessarily assume. Thus, carvers, 
book-binders, engravers, jewelers, printers, shoe-makers, book- 
keepers, and cigar-makers all have a low average duration of 
life. It is found, likewise, that many of these artisans suffer 
most from pulmonary and digestive troubles, among the former 
being phthisis, and among the latter constipation, dyspepsia, and 
haemorrhoids. 

VII. — DISEASES FROM EXPOSURE TO MECHANICAL VIOLENCE. 

It will be seen, by reference to the table on page 209, that 
all persons whose occupations involve an intimate contact with 
machinery, and in the pursuit of which accidents frequently 
happen, have a short duration of life. Persons liable to these 
dangers are machinists, operatives in factories, workmen in 
powder-mills, baggage-masters, brakemen, drivers, engineers, 
firemen, and other workmen on railroads. Aside from the 
diseases to which some of these classes are liable in consequence 
of exposure to variable atmospheric conditions, the grave acci- 
dents to which they are so frequently exposed render their 
occupations extremely dangerous. Brakemen on freight rail- 
roads, for example, are classed by insurance companies as the 
most hazardous " risks," and some companies refuse to take them 
at all. The table on page 209 tends to confirm the conclusion of 
the insurance companies, for, excluding the class of " students," 
which, for manifest reasons, cannot be used as a comparison, 
brakemen have the shortest average duration of life of all the 
occupations noted in the table. 



[The student is referred, for more complete information on 
the subjects considered in the foregoing chapter, to the following 
works : — | 

L. Hirt, Die Kranklieiten der Arbeiter. — Eulenburg, Handbnch derj! 
Gewerbebygiene. — Layet, H3^giene des Professions et des Industries.] -; 



CHAPTER X. 

Military and Camp Hygiene. 

The subjects embraced in this chapter can be most con- 
veniently arranged under the following heads : — 

I. The Soldier and his Training. IV. The Dwelling of the Soldier. 

II. The Food of the Soldier. V. Camp Diseases. 

III. The Clothing of the Soldier. VI. Civilian Camps. 

I. — THE SOLDIER AND HIS TRAINING. 

The relations existing among different nations at the present 
time require that a standing army of greater or less number be 
maintained by each for the common safety. This being the 
case, it needs no argument to prove that such an army should 
be composed of the best material available in order that it may 
be depended upon for defense or offense when necessity demands 
that it should be called into active service. 

Hammond says with truth^ that " a w^eak, malformed, or 
sickly soldier is not only useless but a positive incumbrance " to 
an army. It is of the first importance, therefore, to exclude 
from the military service, by a rigorous physical examination, all 
individuals whose physical condition is defective, who are either 
suffering from or predisposed to disease. 

The foremost authorities on military hygiene are agreed 
that no recruit should be enlisted for actual service before the 
20th year. In the English army the lowest age at present is 
19 years ; in Germany, 20 years ; in France, 20 years for actual 
service {recrues)^ 18 years for enlistment {engages); and in the 
United States, 21 years. The limit of age upward in the latter 
army is 45 years, except in cases of re-enlistments. The height 
of recruits must be at least 165 centimetres; minimum chest 

1 Hygiene, p. 19. Philadelphia, 1863. 

(231) 



232 TEXT-BOOK OF HYGIENE. 

measurement 75 centimetres, with at least 5 centimetres' expan- 
sion ; and weight from 54 to 81 kilogrammes. In the cavalry 
service the maximum weight is 75 Idlogrammes. Every recruit 
must be vaccinated before enUstment. 

The physical examination of recruits before enlistment 
must be made by a medical officer, whose decision, in the United 
States army, is definitive. In the German army the decision of 
the medical officer is not final, but subject to revision by the 
recruiting officer, who may, if he sees fit, overrule the medical 
officer's opinion and enlist a man who has been decided to be 
unqualified for the military service. In this and various other 
respects, such as pay, rank, and effective power, the Medical 
Staff of the United States Army has many advantages over that 
of most foreign armies. 

II. — THE FOOD OF THE SOLDIER. 

The army ration of the United States, which is given below, 
was fixed by regulations before the more-recent researches of 
Professor Voit on nutrition were completed. The ultimate com- 
position, which yields 142 grammes proteids, 116 grammes fats, 
and 435 grammes carbohydrates, shows an excess of fats and 
deficiency of carbohydrates. Table XXI shows the daily allow- 
ance for each soldier : — 

Table XXI. 
342 grammes pork or bacon, or 



567 


u 


fresh beef. 


454 


u 


hard bread, or 


566 


a 


flour. 


68 


u 


beans or peas, or 


45 


u 


rice or hominy. 


45 


li 


green coffee. 


IT 


u 


salt. 


68 


u 


su^ar. 



To this is also added vinegar, pepper, and tea in place of 
coffee. Although the regular food-allowance in the United States 
army is liberal, and is largely in excess of the needs of the soldier 



THE CLOTHING OF THE SOLDIER. 233 

in garrison, medical officers generally agree that in active service 
it is insufficient in quantity and not sufficiently varied. 

The money value of each of the above articles in the ration 
is fixed by the government, and may be drawn instead of certain 
of the articles, and other articles of food purchased and thus 
the dietary varied. The money so drawn constitutes what is 
known as the " company fund." In the hands of a judicious 
commanding officer, the company fund can be made a source 
of great benefit and comfort to the men, but that it is at 
times mismanaged or misapplied is well known to army sur- 
geons. 

Aside from the insufficient quantity and variety of food 
furnished to soldiers, the cooking, especially in temporary camps, 
is often defective and causes digestive derangements and con- 
sequent innutrition. A good cook should be attached to every 
company. 

III. — THE CLOTHING OF THE SOLDIER. 

The clothing of the United States soldier is tolerably well 
adapted to its uses. It is generally well made, and of good, 
serviceable material. The only exception that can be made with 
reason is that the foot-gear is not made to individual measure, 
and hence peculiarities of shape of the feet cannot be taken 
account of. For this reason painful affections of the feet, due to 
ill-fitting boots or shoes, are of frequent occurrence. 

When on a march, the soldier carries his extra clothing 
packed in a knapsack and strapped upon the back. His 
blankets and great-coats are rolled into a cylinder and strapped 
upon the knapsack. The weight each soldier has thus to carry, 
in addition to his arms and ammunition, amounts to considerable. 
There is reason to believe that the pressure produced by the 
straps of a heavy knapsack may cause not only discomfort but 
actual disease. It is believed by many officers that the knapsack 
could be abolished with adA^antage, and the extra clothing rolled 
up in the blanket, or a water-proof sheet, and slung over the 
left shoulder. 



234 TEXT-BOOK OF HYGIENE. 

IV. — THE DWELLING OF THE SOLDIER. 

Soldiers are generally housed either in barracks, huts, or 
tents. The former are usually the habitation of the soldiers 
in garrisons or permanent camps, while huts or tents are 
used for the purpose of sheltering the occupants of temporary 
camps. 

Barrachs. — A military barrack is a one-storied building 
constructed of stone, wood, or iron, or a combination of these 
materials. The general plan of the barrack comprises a large 
room for the beds of the soldiers, one or more smaller rooms 
for the non-commissioned officers of the company or squad, and 
a Avash-room. The sleeping-room of the soldier is also his living- 
or day- room. It is evident, therefore, that sufficient air-space 
and good ventilation must be provided if the soldier's health is to 
be maintained. In England, 17 cubic metres are recommended 
for the initial air-space. In the new barracks constructed in 
France according to the plans of M. Toilet, 22 cubic metres are 
allowed to each occupant. 

The special points of distinction of the system of Toilet, of 
which Schuster says that "to it belongs the future of barrack 
construction," are : The frame of the building is of light-iron 
ribs ; the interspaces are walled up with bricks or stone ; the 
roof is slate ; the ceiling is arched, and all corners are rounded to 
prevent lodgment of dust. Ventilation is provided by openings 
in the walls at the edge of the roof for the entrance of fresh air, 
and by ridge ventilators. 

In France, barracks have been built according to Toilet's 
system at Bourges, Cosne, Macon, and Autun. Although occu- 
pied but a short time, it appears that the health of the soldiers 
remains better in them than in the barracks constructed on the 
old style. The system would seem also especially to lend itself 
to the construction of hospitals. The wash- and bath- rooms of 
the barracks should be so arranged as to encourage the soldier 
to cleanliness. Where the only lavatory in a barrack is, as 
the author has seen it, an open porch, men are not likely to 



THE DWELLING OF THE SOLDIER. 235 

spend much time in cold weather in washing their faces and 
liands, to say nothing of the rest of their bodies. 

The kitchen and dining-room should be detached from the 
building serving as quarters ; otherwise the odors of the cooking 
will pervade the building. 

The sinks or latrines should be placed at some distance from 
the quarters and kitchen, and out of the line of prevailing winds. 
The writer has personal knowledge of a permanent military post 
"within a few miles of the city of Washington, where, only a few 
years ago (and, for aught known to tlie contrary, at the present 
day), " the rear," or place of depositing excrement, was about 
70 metres distant from the kitchen and men's quarters, and 
directly in Hue (to leeward) with the prevailing winds ! 

Before erecting any buildings it is, of course, necessary to 
endeavor to secure a clean and dry subsoil. Attention is called to 
the principles underlying the construction of dwellings, Chap. VI. 

Tents and Huts. — The tents used in the army are the hos- 
pital-tent, the officers' wall- tent, the A -tent, and the shelter- 
tent, w^hich is a modification of the last. The conical, or Sibley 
tent, which was frequently seen in camps in the early part of 
the war between the States, has gone out of use. Soldiers give 
the preference to the shelter tent, which is light, each man's 
piece weighing only 1.18 kilogrammes. Two pieces being 
joined together by buttons and button-holes, and thrown over a 
ridge-pole supported upon uprights, and the four corners fast- 
ened to pegs driven into the ground, form a tent 1.20 metres 
high, 1.65 metres long, and having a spread at the base of 
between 1.8 and 2.1 metres. Such a tent will form a comfort- 
able shelter for two men, unless there should be strong winds or 
driving rains, when the ends could be closed by blankets, brush, 
or an extra piece of shelter-tent. The uprights and ridge are 
steadied by short guy-ropes, one of which is furnished with 
each piece of the tent. 

In winter, especially when camps of more or less perma- 
nence are formed, the soldiers usually build log huts. The 



236 



TEXT-BOOK OF HYGIENE. 



interstices between the logs are plastered up with mud or clay, 
and the roof is formed of canvas, generally several pieces of 
shelter tent joined together. 

The ground around the tent or hut should be trenched in 
order to carry off the rain-falL 

Cleanliness within and around tents or huts is of the first 
importance, and should be enforced in all camps by the proper au- 
thority. Military authorities have long since learned that in the 
matter of cleanliness of body, clothing, or surroundings voluntary 
action on the part of the soldier cannot be relied upon. Frequent 
and thorough inspections will alone secure proper cleanliness. 



V. — CAMP DISEASES. 

The soldier's profession has been aptly characterized by 
Ruskin as " the trade of being slain." In the late war between 
the States, the total deaths of the Federal army numbered 359,496, 
— over 15 per cent, of the entire number of enlistments. Of this 
number, however, 224,586 (nearly two-thirds) died from disease, 
while the remaining 134,910 (a small fraction over one- third) were 
killed in battle or died from the effects of wounds. The colored 
troops especially suffered greatly from the effects of disease. 

Diarrlicea and Dysentery. — The most fatal diseases of camp 
life, especially in time of war, are diarrhoea and dysentery. The 
statistics of the Federal army during the late war are given in 



the following table ^; — 



Table XXII. 



Total Deaths from Diarrho&a and Dysentery in the U. S. Army, from May 1, 1861, 

to June 30, 1S66. 



- 


White Troops, from 

May 1, 1861. to June 

30, 1866. 


Colored Troops, 
from Julv 1, 1863, 
to June 30, 1866. 


Total. 


Acute Diarrhoea .... 
Chronic Diarrhoea . . . 
Acute Dysentery .... 
Chronic Dysentery . . . 


Cases. 

1,155,226 

170,488 

233,812 

25,670 


Deaths. 
2.923 

27.558 
4.084 
3,229 


Cases. 

113,801 

12,098 

25,259 

2,781 


Deaths 

1,868 

3.278 

1,492 

626 


Cases. 

1,269,027 

182,586 

259,071 

28,4-)l 


Deaths 
4.291 

30,836 
5,576 
3,855 


Total 


1,585,196 


37,794 


153,939 


6,764 


1,739,135 


44,558 



» Medical and Surgical History of the War, second medical volume, p. 2. 



CAMP DISEASES. 237 

Owinsr to the fact that a considerable number of deatlis 

o 

were reported ^yithout assigning any cause, 13r. AVoodward esti- 
mates the total number of deaths from the above diseases at 
57,265, or, in the proportion of one death from diarrhoea and 
dysentery to three and one-half deaths from all diseases. Among 
the prisoners of war held by the Confederate States in Anderson- 
ville prison, where tolerably complete records were kept, more 
than half the total deaths were from diarrhoea and dysentery, 
while the ratio of deaths to cases of the above tAvo diseases was a 
fraction over 76 per cent. This frightful mortality from these 
two diseases, both in the prisons and among the armies in the 
field, is principally due to the insanitary conditions surrounding 
the soldiers. Where the demands of hygiene were especially 
ignored ; where the food was bad in quality, or badly cooked ; 
the water impure; the soil polluted by excreta and other filth; 
where the men were exposed to stress of weather or to a paludal 
atmosphere; — under these conditions, the above diseases of tlie 
intestines prevailed in their greatest extent and most fatal 
degree. 

Malarial Fevers. — The diseases due to the paludal poison 
are exceedingly frequent among soldiers encamped in malarial 
sections. During the Civil War a very pernicious form of malarial 
fever received the designation of the locality in which it prevailed, 
and passed into the literature under the name of " Chickahominy 
fever." AYhile malarial diseases were largely represented in the 
morbility reports during the war, the most serious results of the 
influence of the malarial poison were manifested in its eff'ects 
upon patients sick with other diseases. Thus, typhoid fever, 
dysentery, or pneumonia, in a patient saturated with malaria, 
was very much more serious than where this complication was 
absent. In the malarial regions in the interior of the country, 
the Mississippi Valley, and the southern portion of the Western 
Tenitoiies, malarial fevers are among the most prevalent camp 
diseases. Greater attention in locating camps, and care devoted 
to draining the subsoil and maintaining a low level of the ground- 



238 TEXT-BOOK OF HYGIENE. 

water, would doubtless result in improvement in the sickness- 
rate from this cause in the army. 

Tuplioid Fever. — Typhoid fever is prevalent in camps and 
garrisons. As it may be propagated through the medium of 
infected discharges of typhoid patients, it will readily be perceived 
that neglect of the precaution of promptly disinfecting such dis- 
charges will almost inevitably result in spreading the disease, 
either by direct inhalation of effluvia from the patient or excreta, 
of pollution of the drinking-water, or by contamination of the 
soil, and subsequently of the atmosphere, by the intestinal dis- 
charges of the patient. 

PJitliisis. — Especially among troops in barracks phthisis is 
a very fatal disease. Formerly the mortality from it was very 
heavy. Eecent improvements in the hygiene of military posts 
and greater care in selecting recruits have very greatly diminished 
the death-rate from phthisis among soldiers. Acute pulmonary 
affections, such as bronchitis, pleurisy, and pneumonia, are com- 
paratively frequent in camps, being due to exposure. 

Typhus Fever and Scnrvjj. — These two diseases are at the 
present day comparatively rare as camp diseases. They break 
out, however, on every occasion when the laws of hygiene are 
violated by permitting overcrowding, overwork, and underfeeding. 
This is almost certain to occur during war, and hence either 
fully-developed scurvy or a scorbutic taint are almost constant 
accompaniments of an army in the field. Among the allied armies 
in the Crimea, and in the Federal army during the war, scurvy 
and typhus fever claimed a considerable share in the mortality. 

Purulent Conjunctivitis. — This affection of the eyes is fre- 
quent among soldiers. It has even been supposed to be peculiar 
to soldier life, and has hence been termed " military ophthalmia." 
It is contagious, and is probably most often spread by the use 
of basins and towels in common. It is not merely annoying, 
but is a very grave affection, often causing perforation of the 
cornea and destruction of vision. The military surgeon should 
be on the lookout for it, and promptly isolate those infected. 



CAMP DISEASES. 239 

Venereal Diseases. — The contagions diseases of the sexnal 
organs are a veritable sconrge of the soldier's life. The history 
of these diseases is intimately interwoven with the history of 
armies, camps, and wars. The first wide-spread appearance 
of syphilis in the fifteenth century is coincident wdth the siege 
of Naples by the French army under Charles VIII. ^ It has 
since that time been a constant companion of the soldier in peace 
or w^ar, and in all seasons and countries. Some progress tow^ard 
its restriction has, how^ever, been made in recent years in certain 
localities, but there is still wide room for improvement. 

In 1867 the venereal diseases reported in the Prussian army 
WTre 53.9 per 1000 of mean strength. In 1882 this number 
had been reduced to 41 per 1000, in 1863 to 36.4, and in 1884 
to 32.8 per 1000. In the Austrian army there were 81 per 
1000 in 1870, diminishing to 73.5 per 1000 in 1884. In the 
British army the ravages of the venereal diseases w^re so terrible 
that legal measures for their restriction by subjecting prostitutes 
to inspection were taken. In 1859 the proportion of venereal 
disease among the home troops was 400 per 1000. In 1864 
and 1866 the passage and enforcement of the "Contagious Dis- 
eases Act " caused a marked diminution of these diseases. This 
reduction is particularly noticeable in syphilis. The following 
table gives a comparative view of the number of cases of syphilis 
per 1000 in the naval service at ports under the acts, and at 
ports where the acts were not enforced: — 

Table XXIII. 

Ports Under the Acts. Ports Not Under the Acts. 
1860-1863 (no restriction), 75.02 per 1000 70.50 per 1000 

1864-1865 (acts enforced), 79.12 " " 100.00 " " 

1866-1870 (acts extended), 47.19 " " 84.74 '< ^' 

1871-1880, .... 40.64 '' " 99.35 '' " 

In the French army the proportion of venereal diseases was 
53 per 1000 from 1862 to 1866. In 1867 the proportion in- 
creased to 106 per 1000. This increase was attributed to the 

» See article on Syphilis, Chapter XIX. 



240 TEXT-BOOK OF HYGIENE. 

infection during the Mexican campaign. In 1879 the propor- 
tion had again diminished to 65.9 per 1000. 

In the United States Army the venereal diseases numbered 
63 per 1000 among the white and 81 per 1000 among the 
colored troops in 1884. A chart drawn by Major Charles 
Smart, surgeon United States army/ shows in an interesting 
manner how opportunity for infection influences the increase of 
venereal disease. At the breaking out of the war, when large 
numbers of men enlisted, the record shows a rapid increase of 
venereal. When the armies were in the field, and opportunities 
for the pursuit of Venus were few, the proportion of venereal 
decreased. At the expiration of the first triennial period of 
enlistment, the soldier with his final pay and thirty days' fur- 
lough crowded the cities, and entered on a period of dissipation 
which usually sent him back to the recruiting officer with empty 
pockets and an attack of gonorrhoea or syphilis. At this time 
the records show a large number of cases, which gradually 
diminished until the end of the war, when the opportunities 
for infection preliminary to the final muster-out crowded the 
hospitals once more with venereal cases. 

The experience with the Contagious Diseases Act in Eng- 
land points out the true way to limit or entirely extirpate this 
disease among the military and naval forces. An inspection at 
regular intervals not only of public prostitutes, but also of the 
soldiers themselves, and segregation of the infected in hospitals 
until the infective period is past, will do more to limit the 
spread of venereal disease than all other preventive measures, 
public or private, put together. 

YI. — CIVILIAN CAMPS. 

The camps of civil life, whether established for the purpose 
of furnishing a refuge to the inhabitants of cities invaded by 
epidemic diseases, as yellow fever or cholera, or whether for 
religious purposes (camp-meetings), or for recreation (hunting 

* Medical and Surgical History of the War, third medical volume. 



CIVILIAN CAMPS. 241 

and fishing camps, etc.), sliould be organized and managed on the 
same principles as the military camp. The site should be selected 
-with judgment — a clean, dry soil, and abundance of wood and 
-water being requisite lor a healthy camp. A superintendent 
or oiRcer of the day should be appointed, whose duty it is to 
carefully inspect the camp daily, and compel the prompt removal 
of all filth and offal from the immediate vicinity. Cleanliness 
of person, clothing, and household is as important while 
'' roughing it " in camp as at home. Singularly, this is very 
often forgotten by very intelligent people. 

The advantage of a well-administered refugee camp in case 
of yellow-fever epidemics has been clearly shown by the brilliant 
success of the depopulation of Memphis during the epidemic of 
1879 and of various Florida cities and towns in 1888, These 
experiments deserve imitation. 

[The following works on Military and Camp Hygiene 
should be studied in connection with this chapter : — 

Smart, The Hygiene of Camps, in Buck's H3^giene and Public 
Health, vol. ii. — Wolzendorff, Armee Kranklieiten, in Realenc3^clop8edie 
d. ges. Heilk., Bd. I, p. 489. — Schuster, Kasernen, in von Pettenkofer 
und Ziemssen's Handbuch der Hvgiene, II Th., 2 Abth. — Cameron : 
Camps, Depopulation of Memphis, Epidemics of 1878 and 1879. Public 
Health, vol. v, p. 152. — Frolich, Militarmedicin. — Medical and Surgical 
Historj^ of the War, especially the second and third medical volumes. 
— Annual Reports of the Supervising Surgeon-General of the United 
States Marine Hospital Service, 1888-9.] 



16 



CHAPTER XL 

Marine Hygiene. 

The melancholy accounts of the mortality from scurvy, 
dysentery, and typhus fever, which were formerly a part of the 
history of so many naval and passenger vessels, are happily 
now only records of the past. Occasionally, however, careless- 
ness of the authorities, or of those responsible for the safety of 
people who " go down to the sea in ships," results in an out- 
break of one or other of these diseases even at the present day. 
Thus, for the fiscal year ending June 30, 1882, 71 cases of 
scurvy and purpura were reported by the medical officers of 
the Marine Hospital Service. It appears that only in one 
instance (where 6 cases of scurvy had occurred on one vessel) 
was any investigation ordered. A most superficial investigation 
showed that the law relating to the issue of lime-juice had been 
violated by the master of the vessel. No prosecution resulted. 
Such facts indicate that laxness in the enforcement of the regu- 
lations expressly made to prevent this fatal disease may be again 
followed by outbreaks of greater or less gravity. 

I. — THE SAILOR AND HIS HABITS. 

Although the sailor of the present day, especially in the 
naval service, is morally and intellectually far in advance of the 
" Jack Tar " of former days, his life, both afloat and on shore, 
leaves much to be desired on the score of temperance, chastity, 
and purity of thought and speech. The life of a sailor in the 
United States na^y, only thirty years ago, is thus graphically 
described by Medical Director Albert L. Gihon^ : "She was 
manned by a motley crew, of whom Americans were a minority, 

^ Thirty Years of Sanitary Progress in the Navy : Annual address by the President to 
the Naval Medical Society, Washington, 1884. 

(243) 



244 TEXT-BOOK OF HYGIENE. 

and Englishmen, Irishmen, Northmen, and ' Dagos ' constitutec 
the far greater part. Some had just returned from another cruise 
having squandered or been robbed of their three years' pay b] 
the landsharks, who cajoled them, only half sober, to the render 
Yous, to be reshipped, and thence to be herded, uncared for, o 
the receiving-ship, still popularly termed the ' guardo,' unt 
drafted on board the first sea-going vessel. All of them were ii 
debt, most of them insufficiently clad, and unable to properb 
outfit themselves. The wretched herd, who were thus gathere( 
from the purlieus of Water Street, and North Street, and Soutl 
Street, who at night were kenneled worse than dogs, by da 
fed like them — crouching on their haunches around greasy 
mess-cloths, cutting with jack-knives or pulling to pieces with 
grimy fingers the chunks of 'salt horse' and 'duff' which 
made their daily fare, and which later in the cruise were both 
spoiled and scanty, did not constitute an elevating subject for 
contemplation. 

" Stint of good food," continues Dr. Gihon, " w^as, how- 
ever, not the chief of the old-time shell-back's ocean trials. Fed 
like a brute, housed worse than one, however faithfully his labors 
were performed, there was for him only a long, dreary season 
of imprisonment. For him there was no glad holiday on shore, 
when the land broke the monotony of the waste of waters. 
The officers might rush pell-mell out of the ship, but Jack could 
only strain his longing eyes upon the green fields or busy sea- 
ports. Notwithstanding the hardships of the voyage, the 
wretched food, and the outbreaks of disease, the crew were con- 
fined eight months on board ship, before ' general liberty ' was 
given, and then men and boys were sent on shore for forty-eighf 
hours to indulge in a mad revel, and to return crazed by rum, 
battered, and bruised. The poor wretch, first made ravenously 
hungry for dissipation by his enforced confinement, was then 
expected to be temperate in the feast of indulgence offered him, 
and punished with vindictiveness if he sought to gorge himself 
with the poor semblance of pleasure. The ' cat ' had been 



THE SAILOR AND HIS HABITS. 245 

abolished, but half a dozen boys strung upon the poop ' bucked 
and gagged ' ; half a dozen men triced up by their thumbs in 
the rigging ; each of the upriglit coffin-like ' sweat-boxes' with 
its semi-asphyxiated inmate ; the ' brig ' with its bruised and 
bloated crew in irons ; the main-hold with its contingent under 
hatches ; the sick-list swollen out of all proportions by in- 
ebriates, injured men, and venereal cases ; — these were the fruits 
of the general liberty, which, within my professional life, repre- 
sented the sum of sanitary mterest in the man before the 
mast." 

Under such circumstances little could be hoped for in the 
way of personal advancement of the crew. The labors, how- 
ever, of the writer just quoted, and others, among whom may 
be mentioned Wilson and Turner, of the navy, and Woodworth, 
Hebersmith, and Wyman, of the Marine Hospital Service, have 
drawn prominent attention to the unsanitary conditions of the 
sailor's life, and legal enactments have done much to elevate 
him to his proper rank as a human being, entitled to be treated 
with humanity, at least. 

The seaman in the navy is now well clad, and receives an 
abundance of food, of good quality, usually well cooked and 
decently served. " Latrines and bath- and wash- rooms under 
the top-gallant forecastle ; mess-tables and benches ; mess- 
lockers and clothes-lockers ; a place where, and opportunities 
when, men can read and write ; and frequent daily liberty to 
go on shore, if not already common to every vessel, are yet now 
so generally the concomitants of the well-officered and well-dis- 
ciplined and efficient ship, that ere long their absence will be 
accounted a fault." ^ A medical corps, selected after the most 
rigorous examination known to the profession, and provided 
with every aid and appliance of medical science, cares for the 
enlisted sailor and marine when ill or injured, as tenderly as for 
the commissioned officer. 

The sailor in the merchant service, however, is still at the 

* Thirty Years of Sanitary Progress in the Navy, Gihon. 



246 TEXT-BOOK OF HYGIENE. 

mercy of inhuman masters, who exact excessive service in return 
for insufficient food, scanty clothing, miserable lodging, abuse, 
ill-treatment, and neglect when sick or disabled. 

II. — THE PASSENGER. . 

During the ten years from 1870 to 1879, inclusive, passen- 
ger vessels carried 1,561,126 passengers from foreign ports en 
route to New York City. The mean duration of each voyage 
was 13.5 days. Out of the above number of passengers 2518 
died on the voyage, — a death-rate of 1.61 per 1000 for the 
voyage and 43.5 per 1000 per annum. These figures accentuate 
the importance of sanitary improvement in passenger vessels. 
The causes of this excessive mortality among emigrants — for it 
is almost exclusively among the passengers in the steerage, or 
" between decks," that the deaths occur — are overcrowding, im- 
proper feeding, defective ventilation, filthy personal habits, and 
inefficient medical attention when sick. Although overcrowd- 
ing is prohibited by statute, yet in every emigrant vessel that 
arrived in New York during the first nine months of 1880 the 
number of passengers was in excess of the number allowed by 
law.^ The shorter voyages and better sanitary conditions ob- 
tainable since steamships, especially those built of iron, have 
come into general use for the carriage of passengers, have very 
much reduced the mortality on ocean voyages ; but, as just 
shown, the death-rate is still excessively high, and many more im- 
provements in the hygiene of emigrant vessels and of passengers 
are desirable. 

III. — THE SHIP AS A HABITATION. 

As a habitation for the sailor and passenger the ship de- 
mands the attention of the sanitarian. The principal points in 
which he is interested are the construction and ventilation of 
sleeping-apartments, and the means of keeping the entire ship 
clean and free of water and impure air. 

The keel is the foundation of the ship. Branching out 

» Hygiene in Emigrant Ships, Turner, Public Health, vol. vi, p. 24. 



THE SHIP AS A HABITATION. 247 

transversely from it are curved timbers, the ribs, which, with the 
keel, constitute the ship's frame. The ribs are covered exter- 
nally and internally with planking, and the spaces between the 
two coverings are the frame-spaces, which are usually partly 
filled with hlthy water, decomposing organic matter, and foul 
air. The water collects in the bottom of the vessel, the bilge,^ 
whence it is pumped out of the vessel. If the pumping is 
neglected the bilge-water becomes very ofFensiTe, and may cause 
disease in persons exposed to exhalations from it. The frame- 
spaces are rarely ventilated, and hence are frequent sources of 
pollution of air on board vessels. 

The sleeping-apartments of the crew of a merchant vessel 
are in the forecastle, usually a small, dark, damp, filthy, unven- 
tilated space in the bow of the vessel, where they are kenneled 
like brutes. On naval vessels the crews sleep on the berth- 
deck, which, in the rarest instances, is properly lighted and 
ventilated. The berth-deck is usually below the water-line. 
In nearly all and even the best class of vessels in the United 
States navy the air-allowance for each man is less than 3 cubic 
metres, rarely reaches 4, is oftener from 2 to 2|, and is some- 
times as low as 1 cubic metre. The men swdng by night in 
hammocks suspended from the beams overhead, and removed 
when not in use, carried on deck, and stored in lockers, called 
"hammock-nettings," on the ship's sides. 

That a ship should, above all, be seaworthy would seem to 
require no argument. It is self-evident that a leaky or rotten 
ship is at all times a highly dangerous habitation, yet crews and 
passengers are almost daily exposed to the perils of shipwreck 
in unseaworthy vessels, especially in the mercantile marine. ^ 

"Dampness, dirt, foul air, and darkness," according to 
Gihon, " are the direst enemies with which the sailor has to 
battle when afloat."^ The first requisite for a healthy ship is 

1 Hence called "bilge-water." 

2 The Safety of Ships and Those who Travel in Them, Woodworth, Public Health, 
vol. iii, p. 79 et seq. 

' >'aval Hygiene, 3d ed., p. 28. 



248 TEXT-BOOK OF HYGIENE. 



J 



dryness. "A damp ship is an unhealthy ship," says Fonssa- 
grives, the greatest authority on naval hygiene. From official 
reports it appears that the relative humidity of the berth-deck 
of vessels in the United States navy is nearly always above 80 
per cent., very often rising to 90 and 95 per cent.^ From the 
same source it is learned that the class of respiratory diseases I 
famished, with one exception, the largest amount of sickness in 
the navy during the year 1880. It is the concurrent testimony 
of all authorities in marine hygiene that the vicious custom of 
daily drenching the decks with water, under the plea of cleanli- 
ness, is mainly responsible for this excessive moisture and its 
results. The battle of naval hygiene was long fought on this 
contested field of wet decks, until the fact became so patent that 
wet ships were always unhealthy ones. It is, therefore, one 
of the most important aims of marine hygiene to curtail this 
practice. 

Gihon recommends that the decks be painted and then 
coated with shellac, occasionally renewed, to make them non- 
absorbent, and to wet them as rarely as possible, consistent with 
cleanliness, the smooth surface of the shellacked deck being 
quickly swabbed over with hot water and thoroughly dried. 

The ship should be dean and ivell ventilated. Efforts to 
keep a ship clean should not be expended upon the decks only; 
the occupied apartments below the hatches, the bilges and frame- 
spaces should all receive especial attention from the sanitary 
inspector. 

It is quite frequently necessary to remove the flooring of 
the vessels in order to expose the accumulations of filth, wdiich 
often make an infected ship synonymous with a dirty ship. An 
unobstructed passage, to which ready access can be had through 
removable covers, should extend under the flooring from one 
end of the vessel to the other. To disinfect a dirty ship, steam 
forced into the hold under pressure, before and after the filth 
has been cleaned out, gives the most satisfactory results. 

» Report of Surgeon-General of the Navy, "Washington, 1880. 



THE SHIP AS A HABITATION. 249 

Fumes of sulphur burned in the presence of watery vapor, and 
chlorine are next in efficiency.^ Solutions of sulphate of iron 
or chloride of zinc may be poured into the bilges to prevent 
decomposition. 

It has been estimated^ that a minimum of 15 cubic metres 
of air-space, with facilities for thorough ventilation, should be 
allowed to each person on board ship. It is safe to say that no 
vessel that floats gives to her passengers or crew the advantages 
of such conditions. Ventilation of the holds and bilges, and of 
the spaces between the timbers or ribs, "intercostal ventilation," 
as Turner calls it, is especially necessary. Any system of ven- 
tilation that does not contemplate the removal of the foul bilge- 
air is unworthy of consideration by the sanitarian. The venti- 
lating apparatus which has been introduced on board vessels of 
the United States navy consists essentially of two longitudinal 
mains extending through the holds and under the engines, boil- 
ers and coal-bunkers the entire length of the ship, beginning in 
contracted extremities at bow and stern and terminating in a 
chamber or " blower-room " on the berth-deck just forward of 
the mainmast. In this room a Sturtevant fan or blower, 2 metres 
in diameter, is driven by an engine at from 150 to 300 revolu- 
tions a minute, expelling the air through a 70-centimetre funnel, 
opening high above the spar-deck. Small metal pipes connect 
these longitudinal mains with every state-room, store-room, 
pantry, and other inclosed apartment on the berth-deck, orlop, 
and holds, from which the foul air is aspirated by the revolution 
of the fan. 

Fresh air finds its way below through the wind-sails, 
ventilating-shafts, hatchways, and air-ports, entering the apart- 
ments by way of doors, crevices, and other natural apertures. 
Similar small metal pipes also connect the bilges with the longi- 
tudinal mains, and air is thus drawn through the frame-spaces 
between the timbers, which terminate below at the floor of the 

* Report of Committee on Disinfectants, American Public Health Association. 

* Hygiene of Emigrant Ships, Public Health, vol. vi, p. 26. 



250 TEXT-BOOK OF HYGIENE. 

ship and open above on the spar-deck, and a circulation of fresh 
air is thus estabhshed m the frame or " skin " of the ship, con- 
tributing greatly to its dryness and to the preservation of the 
material of the vessel. The absolutely essential condition of this 
system of ventilation is that the blower shall revolve, but, 
unfortunately, sanitary interests are too often sacrificed on tlie 
pretext that economy of fuel will not permit the operation of the 
fan.^ 

All parts of the vessel used as habitations or sleeping- 
apartments should receive sufficient sunlight. At present, very 
few vessels have the quarters of the crew so disposed as to admit 
any sunshine at all. 

In the fire-rooms of steamships, especially on that class of 
naval vessels termed monitors, the temperature often rises so 
high as would seem to render continued existence in it impossi- 
ble. Gihon states that the average temperature in the fire-room 
of the monitor Dictator was 145° F. (63° C), while Turner 
states that in another vessel the average fire-room temperature 
was 167° F. (75° C.).^ The firemen and coal-heavers (stokers) 
frequently sufi'er from heat-stroke, and, in a very large proportion 
of cases, from heart disease. 

Lavatories and bathing facilities should be furnished on 
vessels for passengers and crew, and both should be compelled 
to keep their bodies and clothing clean. A more liberal supply 
of water for drinking, a more frequent issue of fresh meat and 
vegetables, and better cooking are the sanitary considerations 
to-day in the subsistence of the sailor. The American naval 
ration is superior in variety and palatableness to that of any 
foreign service, but skilled cooks are still a desideratum on 
board men-of-war, and medical officers have long been insisting 
that schools for tlieir instruction should be estabhshed at recruit- 
ing stations. The composition and distribution of the rations are 
given in the following table : — 

» Hygiene (Naval), Hand-book of the Medical Sciences, Gihon. 
« Buck's Hygiene and Public Health, vol. ii, p. 190. 



TEE SHIP AS A HABITATIOIS*. 



251 



Table XXIV. 

ALLOWANCE FOR GENERAL DAILY USE. 

(Either one of the foUoAvmg.) 



Rations Established 
bv Law, 



Specified by Law. 



Substitutes Authorized bv Law. 



Ration No. 1 



Ration No. 2 



Ration No. 3 



Ration Xo. 4 . 



f 1 1 lb. salt pork \ 

^ pint beans or peas . 



1^ lb. fresh meat ; or, 
f lb. preserved meat, 
( Vegetables of equal value ; or, 
^ ^ lb. rice. 



1 lb. salt beef ( 

i lb. flour I 

2 ozs. dried fruit .... 

1 lb. preserved meat . . 
^ lb. rice 

2 ozs. butter 

11 oz. desiccated mixed 

vegetables 



C ^ 



f lb. preserved meat . . 

ozs. butter 

ozs. desiccated tomatoes 



1^ lb. fresh meat ; or, 
^ lb. preserved meat. 
Vegetables of equal value. 

Xo substitute. 

^ pint beans or peas. 

Ko substitute. 

6 ozs. canned vegetables. 

Xo substitute. 
Xo substitute. 
6 ozs. canned tomatoes. 



DAILY ALLOWANCE. 



Rations Established 
bv Law. 



Specified by Law. 



Ration Xo. 1 . . 14 oz. biscuit 
Ration Xo. 2 . . ^ oz. tea . . 



Ration Xo. 3 . . 



4 ozs. sugar 



Substitutes Authorized by Law. 



1 lb soft bread. 

1 lb. flour. 
I" lb. rice. 

2 ozs. coff'ee. 
2 ozs. cocoa. 

For coff'ee and sugar, extract of 
coff'ee combined with milk and 
sugar maj^ be substituted by the 
Secretary of the Xavy, if not 
more expensive. 



WEEKLY ALLOWANCE. 



Rations Established 
bv Law. 



Specified by Law. 



Substitutes Authorized by Law. 



Ration Xo. 1 
Ration Xo. 2 
Ration Xo. 3 



2^ pint pickles . 
^ pint molasses 



Xone. 
Xone. 
Xone. 



• These articles being out of the market, and not procurable, the nearest possible sub- 
stitutes are given. 

9 One-half pint of pickles is considered equal to 34 It)., and is issued as such. 



252 TEXT-BOOK OF HYGIENE. 

lY. — DISEASES ON SHIPBOARD. 

The diseases most liable to attack persons on shipboard 
are : Diseases of the respiratory organs, rheumatism, malarial 
diseases, digestive disorders, scurvy, typhus fever, and skin 
diseases ; and, where the infection has been conveyed to the 
vessel by other persons or by fomites : yellow fever, cholera, 
small-pox, and venereal diseases. It is interesting to note in the 
last-published report of the Surgeon-General of the Navy that, 
among a total of 8550 admissions of sick and disabled officers 
and men of the Navy and Marine Service, nearly 90 per centum 
were included in the following classes, to wit : — 

Casualties, 191T 

Affections of the respiratory tract, . . .1149 

Yenereal diseases, 1071 

Malarial and other fevers, 888 

Diseases of the integument, .... 888 

Rheumatism, 521 

Affections of the nervous sj^stem, . . . 489 

Diarrhoeal maladies, 483 

The remaining 1144 were distributed over a wide range of 
titles, of which many, as adynamia, cephalalgia, constipation, 
odontalgia, etc., have no special pathological significance. It is 
probable that only about one-fourth of the cases of disease 
occurring at sea are attributable to any of the circumstances of 
oceanic life, and these are almost entirely inflammatory affections 
of the air-passages and intestinal tract, neuroses, including 
nausea marina, and rheumatism.^ 

Most of these affections can be prevented by proper meas- 
ures of hygiene, as demanded by the conditions described in this 
chapter or by the enforcement of the following regulations : — 

Inspection of crews and passengers should be made com- 
pulsory before shipment. Persons suffering from contagious or 
infectious diseases should not be taken on board/^ In order to 

» The Therapy of Ocean Climate, Gihon, Transactions of American Climatological Asso- 
ciation, 1889. 

2 Gihon relates an instance where a man suffering from parotitis was transferred from 
the hospital of a receiving-ship to a vessel going to sea. The disease was communicated to 
more than seventy of the crew of the latter vessel. 



DISEASES ON SHIPBOARD. 253 

make this provision effective, the history of the individual for 
two weeks prior to his appUcation for shipment shoukl he known 
to the inspecting officer. Passengers should possess bills of 
health from the local authorities at their homes, in order that 
the presence or absence of such diseases as small-pox, yellow 
fever, cholera, or plague may be established by the inspector. 
Cholera has always been introduced into this country by immi- 
grants. Everybody admitted to the ship should be vaccinated. 
During several years past a number of epidemics of small-pox 
have been traced to foreign immigrants who had not been 
properly vaccinated. 

Sailors in the merchant service should, like those in the navy, 
be submitted to a close personal inspection, and those suffering 
from venereal diseases should be rejected. The usual history 
of the cases is that they soon go on the sick-list, and thus 
become an incumbrance instead of an aid on the vessel. 
Statistics show that 1 man in every 7 or 8 in the naval service 
and 1 in every 4 of the crews of merchant vessels are affected 
wdth some form of venereal malady.^ These inspections should 
not be restricted to examinations for venereal diseases, but indi- 
viduals incapacitated for the performance of a seaman's duties 
by any cause should be rejected. This precaution would un- 
questionably reduce the number of marine disasters directly 
traceable to deficiency in the working force on board vessels. 
In this country the services of the medical officers of the Marine 
Hospital Service might be made available to carry out these 
inspections. 

All sailors are liable to be placed in positions where the 
prompt and accurate distinction of colors becomes necessary, 
hence all color-blind individuals should be rejected as seamen. 
The inability to distinguish colors has often been the cause of 
grave accidents at sea. Pilots can no longer obtain a license 
unless they satisfactorily pass an examination with reference to 
their ability to distinguish colors. 

» The Prevention of Venereal Diseases, Gihon, Public Health, 18^. 



254 TEXT-BOOK OF HYGIENE. 

[The following works contain more detailed information 
upon the subject treated in the foregoing chapter: — 

A. L. Gihon, Practical Suggestions in Naval Hygiene, 3cT ed., 
Washington, 18t3. — T- J. Turner, Hygiene of the Naval and Merchant 
Marine. — Buck's H3^giene and Public Health, vol. ii. — Walter Wj-man, 
Hygiene of Steamboats on the Western Rivers. — Keport of Supervising 
Surgeon-General M. H. Service for 1882. — Annual Reports of the Surgeon- 
General of the Navy for 1879, 1880, and 1881.— Yarious papers by J. M. 
Woodworth, A. L. Gihon, T. J. Turner, Hebersmith, and A. N. Bell in 
Public Health, vols, i, iii, and vi. — Hj^giene, Naval, by Albert L. Gihon, 
M.D., in Reference Hand-book of Med. Sciences.] 



CHAPTER XII. 

Prison Hygiene. 

Although the frightful mortality which formerly seemed a 
necessary accompaniment of the life of the convict has in the 
past half-century markedly diminished, the death-rate among 
prisoners is still very greatly in excess of that of persons of the 
same age in a state of liberty. 

The observations and labors of John Howard, the self- 
sacrificing philanthropist, in the latter half of the last century, 
and of Elizabeth Fry, in the first half of the present, directed 
the attention of legislators to the necessity of reform in the con- 
duct of prisons and the treatment of prisoners. As a conse- 
quence of the labors of these reformers, the principles of prison 
discipline have been more fully developed during the past forty 
years by students of social science everywhere, and certain 
propositions have been formulated, which govern, to a greater 
or less degree, legislation upon this subject. These propositions 
are, briefly, as follow : — 

Prisoners must be properly classified according to the 
nature of their crime and the duration of imprisonment. 

The two sexes must be strictly separated, and no oppor- 
tunity given for intermingling while in the prison. 

Female prisoners should have female attendants exclusively. 
Male watchmen or other attendants should not be allowed in 
the female department of a prison. 

All prisoners must be kept employed at some manual labor, 
not necessarily for profit, but as an agency in the moral reforma- 
tion of the convict. 

Punishments for infractions of discipline must not be 
excessive. 

(255) 



256 TEXT-BOOK OF HYGIENE. 

Efforts should be constantly made tending to the reclama- 
tion of criminals from their life of sin and crime. 

Due care must be taken by the State to preserve the health 
and life of the prisoner whom the State has deprived of liberty 
and the opportunity of taking care of himself 

A proper classification of prisoners, according to the degree 
of their criminality, the nature of the crime of which they have 
been convicted, or the length of time for which they have been 
sentenced, is now insisted upon by all students of prison dis- 
cipline. As this subject more nearly concerns the social or legal 
relations of prisoners rather than their sanitary interests, it is 
here passed over with a mere mention. 

The separation of the sexes, necessity of female attendants 
on prisoners of the same sex, employment of prisoners, and moral 
reformation of criminals likewise belong especially to the social 
aspects of the question, and can find no discussion in this place. 

Regarding the remaining proposition, however, that which 
demands that the State shall exercise due care over the prisoner's 
health, it comprises a question that demands consideration in a 
text-book on hygiene. 

There is now a general concurrence of opinion that the 
State, in depriving any person of liberty, has no right to subject 
the individual suffering such deprivation to any danger of disease 
or death. In other words, the State has no right to abbreviate 
the life of the convict sentenced to prison. This proposition 
requires that the State see to it tliat the prisoner is well fed, 
well clothed, and well housed ; that he shall be well cared for 
when sick, and that when his term of imprisonment expires he 
shall be set at liberty, with only such effect upon his normal 
expectation of life as would result from the ordinary wear and 
tear of Yih upon his health. 

It must be confessed, however, that the State is very far 
short of attaining this object. The mortality of convicts, even 
in the best-regulated prisons, where especial attention is paid to 
the sanitary requirements of such buildings, is three times as 



PRISON HYGIENE. 257 

great as among workmen in mines, confessedly one of the most 
dangerous occupations. If insurance companies desired to 
insure the lives of prisoners, the companies would be obliged, in 
order to secure themselves against loss, to make the premium 
equivalent to an advance in age of twenty years. This means 
that a free person has as long an expectation of life at 40 
years as a prisoner has at 20. Attention is again called to 
the fact that the conditions in the most favorably situated and 
liberally managed prisons only are here considered. What the 
results are in other institutions, less favorably constructed and 
managed, will be apparent from the following brief statement : 
Mr. George W. Cable has shown ^ that in some of the prisons 
in the Southern States, under the vicious lease system, the 
mortahty is eight to ten times greater than in properly con- 
structed and managed prisons elsewhere. In Louisiana, for 
example, 14 per cent, of all the prisoners died in 1881 ; and in 
the convict wood-cutting camps of the State of Texas one-half 
of the average number so employed during 1879 and 1880 died. 

The mortality of prisoners is greatest in the second, third, 
and fourth years of their confinement. In Millbank Prison, in 
England, the death-rate per 1000 was 3.05 in the first year, 
35.64 in the second, 52.26 in the third, 57.13 in the fourth, and 
44.17 in the fifth years of imprisonment. 

The diseases most frequent among prisoners are pulmonary 
phthisis and diseases of inanition, manifested by general dropsy. 
Consumption furnishes from 40 to 80 per cent, of all deaths. 
When prisoners are attacked by acute febrile or epidemic diseases 
(small-pox, cholera, dysentery), the mortality is much higher 
than among persons in a state of liberty. This fatality is due 
to an anaemic or cachectic condition, which has been called " the 
prison cachexia," — a depravement of constitution which yields 
readily to the invasion of acute diseases. 

Prisons should be built upon a healthy site, be properly 
heated and ventilated, have an abundant water-supply, and 

* Century Magazine, February, 1884. 
17 



258 TEXT-BOOK OF HYGIENE. 

be supplied with facilities for a prompt and thorough removal 
of sewage. Baths and lavatories should be conveniently ar- 
ranged in order that thorough cleanliness can be enforced. 

The problem of feeding prisoners requires careful study. 
The food should not only be sufficient in quantity and of good 
quality, but it should be well cooked, and the bill of fare varied 
often in order to avoid creating a disgust by an everlasting 
sameness. Prisoners often suffer from nausea and other digestive 
derangements, brought on solely by the monotonous character 
of the daily food. 

In workshops and sleeping-rooms, dormitories or cells, the 
cubic air-space allowed to each inmate should not be less than 
17 cubic metres, with proper provision for ventilation. The 
use of dark or damp cells as places of confinement is a relic of 
the barbarism in the treatment of convicts against which John 
Howard raised his voice so effectively in the last century. An 
abundance of sunlight should be admitted into every room in 
which a human being is confined. 

An important hygienic measure is daily exercise in the 
open air. It should be regularly enforced, and its modes 
frequently varied in order that it may not degenerate into a 
mere perfunctory performance. 

Punishment for infractions of the prison discipline should 
be inflicted without manifestation of passion, and only under the 
immediate direction of some official responsible to the State. 
It is questionable whether physical punishments, such as 
whipping, tricing up by the thumbs with the toes just touching 
the floor, bucking and gagging, and similar barbarities should 
be permitted under any condition. The permission to exercise 
such power is extremely liable to be abused by officials. The 
system of leasing out prisoners to private parties, which prevails 
in some of the southern United States is vicious in the extreme, 
because it places the convict under the control of persons not 
responsible to the State, and, in the majority of instances, morally 
unfitted to wield the power of inflicting punishment. 



PRISON HYGIENE. 259 

[The following works on prison hygiene and prison reform 
are recommended to the student : — 

A. Baer, Gefangniss-H^'gieiie, in von Pettenkofer und Ziemssen's 
Handbuch der H^^giene, II Th., 2 Abtli. — Trans. International Peniten- 
tiary Congress, London, 1882. — Trans. National Prison Association, 
Baltimore, 1872. — G. W. Cable, The Convict-Lease System in the South- 
ern States, Century Magazine. February 1884.] 



CHAPTEH XIII. 

Exercise and Training. 

The healthy functions of the bodily organs can only be 
maintained by more or less constant use. A muscle or other 
organ that is unused soon wastes away, or becomes valueless to 
its possessor. On the other hand, trained use of the various 
organs makes them more effective for the performance of their 
functions. Thus, by practice, the eye can be trained to sharper 
vision, the ear to distinguish slight shades of sound, the voice to 
express varying emotions, the tactile sense to accurately appre- 
ciate the most minute variations of surface and temperature, and 
the hand to greater steadiness or the performance of difficult 
and complex feats. The effectiveness of other organs, muscles, 
or groups of muscles can also be increased by systematic train- 
ing, as is seen in the athlete and gymnast. 

PHYSIOLOGICAL EFFECTS OF EXERCISE. 

"Wlien a muscle contracts, the flow of blood through it is 
increased. Hence, contraction of a muscle, which consumes or 
converts stored-up energy, at the same time draws upon the cir- 
culation for a new supply of food-material to replace that con- 
sumed. The activity of the circulation through a muscle in 
action results in increased nutrition and growth of the muscle. 

During muscular action the activity of the respiratory 
process is increased. A larger quantity of air is taken into the 
lungs, more oxygen is absorbed by the blood, and an increased 
elimination of carbon dioxide takes place. The experiments of 
Pettenkofer and Voit show that, while in a state of rest the 
average absorption of oxygen in twelve hours amounted to 708.9 
grammes, during work the amount reached 954.5 grammes. 

(261) 



262 TEXT-BOOK OF HYGIENE. 

For the same period the ehmination of carbonic dioxide was: 
during rest, 911.5 grammes; during work, 1284.2 grammes. 

Upon the circulation muscular exercise likewise exerts a 
manifest influence. The action of the heart is increased both in 
force and frequency, the arteries dilate, and the blood is sent 
coursing through the system more rapidly than when the body 
is at rest. 

Cutaneous transpiration is also promoted by muscular exer- 
cise. It is probable that in this way some of the effete matters 
in the system are removed, being held in solution and carried 
through the skin in the perspiration. 

PHYSICAL TRAINING. 

There can be no question that systematic training of the 
muscles has a favorable influence upon health and longevity. 
Persons who are actively engaged in physical labor, other things 
being equal, are healthier, happier, and live longer than those 
whose occupation makes slight demands upon their muscular sys- 
tem. In default of an active occupation the latter class is forced, if 
good health is desired, to adopt some form of exercise which 
will call the muscles into activity. 

The principal methods of physical training are walking or 
running, rowing, swimming, and the various in-door gymnastic 
exercises. Rapid walking or running is one of the best methods 
of physical exercise, for, not only are the muscles of the legs and 
thighs developed, but the capacity of the chest is increased — one 
of the principal objects of physical training. By combining 
walking with some form of in-door gymnastics, such as practice 
with dumb-bells, Indian clubs, rowing-machines, or pulley- 
weights, nearly all the good effects of the most elaborate system 
of training can be obtained. 

For the gymnastic exercises various forms of useful labor 
may be substituted with advantage, such as wood-chopping or 
sawing, or moderate work at any physical labor. 

The scheme of studies in our public-school system should 



PHYSICAL TRAINING. 263 

include physical training for both sexes. This is a question not 
merely of individual, but of national importance. Weak and 
unhealthy children are not likely to grow up into strong and 
healthy men and women; and the latter are necessary for the 
perpetuity of the nation. The time seems to have arrived when 
physical education should no longer be looked upon as a whim 
of unpractical enthusiasts and hobby-riders, but as an indispen- 
sable element in every school curriculum. 

There is a tendency among instructors in physical training 
to make their systems too complicated, or dependent upon expen- 
sive or cumbersome apparatus. This is to be deprecated. All 
the muscles of the body can be called into action by very simple 
exercises, easily learned and readily carried out. 

An important preliminary to all methods of training is a 
thorough physical examination of the pupil by a competent 
physician, in order to determine whether certain exercises are 
allowable. For example, in all organic heart affections exer- 
cises of a violent character must be interdicted. A boy or man 
with valvular disease of the heart cannot run, row, or swim 
with safety. The organ is easily overtasked in this condition 
and liable to fail in its function. 

One of the simplest and best methods to cause the pupil to 
assume a correct position of the body, and to acquire ease and 
grace in his movements, is to teach him the "setting-up," as 
practiced in the United States army.^ 

In walking, a free, swinging step should be acquired, with 
the head erect, shoulders thrown back, and chest well to the 
front, the whole body from the hips upward inclining slightly 
forward. The clothing should be loose around the upper part 
of the body, in order not to interfere with the freest expansion 
of the chest, and to give the lungs and heart ample room for 
movement. Even in-door gymnastic exercises alone, when prac- 
ticed under intelligent provision, will accomplish very favorable 
results, as shown by the following table: — 

1 Upton's Infantry Tactics. School of the Soldier, Lesson I. 



264 



TEXT-BOOK OF HYGIENE. 



Table XXY. 

Showing Average State of Development on Admission to Gymnasium ; Average State 
of Growth and Development after Six Months' Practicing Two Hours a Week, 
and Average Increase During that Time. (Bowdoin College Gymnasium, under 
Dr. D. A. Sargent. Two Hundred Students from the Classes of 1873 to 1877, 
inclusive. Average Age, 18.3 Years.y 



On Admission. 



After Six 
Months' 
Practice. 



Average 
Increase. 



Height ■ 

Weight 

Chest (inflated) . 
Chest (contracted) 
Forearm . . . 

Upper arm (flexed) 
Shoulders (width) 

Hips 

Thigh 

Calf 



170, 
60 
87 
80 
35 
27 
38 
78 
48 
31 



cm. 

7 kg. 
5 cm. 



170 6 cm. 
61 6 kg. 
91.8 cm. 
82.4 " 
26.8 " 
29 " 
405 " 
84.4 " 
52.6 " 
33. " 



.6 cm. 

900 gms. 
4 3 cm. 

1.8 " 
1.8 " 
15 " 
1.8 " 

5.7 " 



OVEREXERTION. 

However necessary for the preservation of health physical 
exercise may be, overexertion should be carefully avoided. 
Overstrain and hypertrophy of the heart are often the results of 
excessive exertion. Dr. Da Costa has described a form of '' irri- 
table " and weak heart occurring especially among soldiers, which 
he has clearly traced to overexertion. Severe labor and violent 
athletic exercises have been followed by like serious results. 
Long-distance pedestrianism has furnished within recent years 
quite a number of individuals who were broken down in health 
by the excessive strain on the physical organization involved. 
Cardiac strain is not infrequent among this class. 

Spasm, paralysis, or atrophy of muscles sometimes results, 
when these are exhausted by uninterrupted or excessive exer- 
cise. This effect is shown by writers' and telegraphers' cramp, 
and similar affections. For these reasons it is important that 
both exercise for health and actual work should be so regulated 
as to conduce to the individual's benefit, and not to his detri- 
ment. 

* Apparatus used : Weights, 4500 to 6750 grammes ; Dumb-bells, 1125 grammes ; Indian 
clubs, 1575 grammes ; Pulleys. 



OVEREXERTION". 265 

[On the subjects embraced in this chapter the following 
works may be studied with advantage : — 

A Braynton Ball, Pli3'sical Exercise, in Buck's Hj^giene and Public 
Health, vol. i. — Wm. Blaikie, How to Get Strong and How to Sta}' So. — 
A. Maclaren, Training in Theory and Practice.] 



CHAPTER Xiy. 

Baths and Bathing. 

The most important sanitary object of bathing is cleanli- 
ness. A secondary object of the bath is to stimulate the func- 
tions of the skin, and to produce a general feeling of exhilaration 
of the body. Baths are used of various temperatures. A cold 
bath has a temperature of from 4° to 24° C. (40° to 75° F.) ; a 
tepid bath from 24° to 30° C. (75° to 85° F.), a warm bath from 
30° to 38° C. (85° to 100° F.), and a hot bath from 38° to 43° 
C. (100° to 110° F.). 

Tepid,, ivarm, or hot haths are used principally as cleansing 
agents or as therapeutic measures. They cause dilatation of 
the cutaneous capillaries, diminish blood-pressure, and reduce 
nervous excitability. The hot bath is also a method for restor- 
ing warmth to the body in certain cases of shock, or to remove 
the immediate effects of injurious exposure to low temperature. 

The so-called Russian and Turkish baths, so popular in the 
larger cities of this country, are modifications of vapor- and hot- 
air baths, or rather combinations of these with cold baths. The 
Turkish bath is especially to be recommended for its depurative 
and invigorating effects. 

Cold hatlis are used not merely for their cleansing effects, 
but principally for their stimulating effects upon the system. 
When first plunging into a cold bath there is usually a moment- 
ary shock; the respiration is gasping, and the pulse is increased 
in frequency. These symptoms disappear in a few moments, 
however, and reaction follows. To a healthy person a cold bath 
is a delightful general stimulant, removing the sense of fatigue 
after physical exertion and causing an extremely refreshing 
sensation throughout the body. 

(267) 



268 TEXT-BOOK OF HYGIENE. 

As a therapeutic measure, the cold bath has a wide field 
of usefulness. For the reduction of the bodily temperature in 
fevers and inflammatory diseases, and especially in heat-stroke, 
it is more prompt and effective than any other agent at the com- 
mand of the physician. 

Sea-Bathing. — The most stimulating form of the cold bath 
is doubtless the salt-water bath as taken at the sea-shore. The 
revulsive eff'ect of the impact of the waves and breakers upon 
the skin and the stimulation due to the saline constituents of 
the sea-water heighten the invigorating effects of the simple cold 
bath. The beneficial results of sea-bathing are, however, not 
entirely due to the bath, but are to a great degree dependent 
upon the bracing air of the sea-shore, absence of the care and 
anxieties of business, and the temporary change in food and 
habits that a residence at the sea-side involves. Nevertheless, 
salt-water baths are more stimulant to the skin than those of 
simple water, and part of the good effects of sea-bathing can 
often be obtained from a salt-water bath taken at home. The 
following mixture of salts dissolved in about 125 litres of water 
for one bath makes a fairly good substitute for a sea-bath : — 

Take of Chloride of sodium (common salt), . . .4 kilogrammes. 
Sulphate of sodium (Glauber's salt), . . . 2 " 

Chloride of calcium, | kilogramme. 

Chloride of magnesium, . . . . • Ij kilogrammes. 

There is a prevalent popular belief that it is extremely dan- 
gerous to enter a cold bath when heated or perspiring. The 
author is of the opinion that this belief is erroneous. The stim- 
ulant and bracing effects of the cold bath are most manifest if it 
be taken while the individual is very warm or bathed in perspira- 
tion. Several years ago the author made a series of observations 
upon himself to determine the effects of the cold bath when 
the body was very Avarm. Every afternoon a free perspiration 
was provoked by a brisk walk of about 2 kilometres in the sun. 
As soon as the clothing could be cast off, and while the body 
was still freely perspiring, a plunge was taken into a fresh-water 
bath of about 15.5° C. (60° F.). No ill results followed; on 



RULES FOR BATHING. 269 

the contrary, the sensation immediately following the bath, and 
for six or eight hours afterward, was exceedingly pleasant. The 
health remained perfect, and the weight decidedly increased 
during the two months the practice was continued. There is 
probably no danger to a healthy person in this practice, but it is 
considered advisable to immerse the head first (" take a header "), 
to avoid increasing the blood-pressure in the brain too greatly, 
which might result if the body were gradually immersed from 
the feet upward. 

RULES FOR BATHING. 

The followino^ series of rules have been issued bv the 
English Royal Humane Society, and are all worth observing by 
bathers : " Avoid bathing within two hours after a meal. Avoid 
bathing when exhausted by fatigue or from any other cause. 
Avoid bathing when the body is cooling after perspiration. 
Avoid bathing altogether in the open air, if, after having been 
a short time in the water, there is a sense of chilliness, with 
numbness of the hands and feet; but bathe when the body is 
warm, provided no time is lost in getting into the water. Avoid 
chilling the body by sitting or standing undressed on the banks 
or in boats, after having been in the water. Avoid remaining 
too long in the water, but leave the water immediately if there 
is the slightest feeling of cliilliness. The vigorous and strong 
may bathe early in the morning on an empty stomach. The 
young, and those who are weak, had better bathe two or three 
hours after a meal ; the best time for such is from two to three 
hours after breakfast. Those who are subject to giddiness or 
faintness, or suffer from palpitation or other sense of discomfort 
at the heart, should not bathe without first consulting their 
medical adviser." 

To these instructions may properly be added that a warm 
or hot bath should be avoided, if the person is liable to ex- 
posure to cold within a few hours after the bath; that women 
should, as a rule, not take a cold bath while menstruating, or 
during the last two months of pregnancy; and that persons 



270 TEXT-BOOK OF HYGIENE. 

suffering from organic heart disease should especially avoid surf- 
bathing. 

After bathing the body should be thoroughly dried with 
soft towels, otherwise eczematous eruptions are liable to follow 
in the parts subject to friction from opposing surfaces of the 
skin, as in the groins, the perinseum and inner surface of the 
thighs, the armpits, or the under surface of the breasts in 
women in whom these organs are large and pendant. 

Friction of the skin with a coarse towel, or so-called 
" flesh-brush," is a popular practice, but is not to be universally 
commended. The hyperaemia of the surface thus produced 
may sometimes induce cutaneous diseases (erythema, eczema, 
psoriasis) in those predisposed. 

DANGERS OF COLD BATHING. 

One of the most serious dangers of cold bathing, but which 
is not sufficiently appreciated, is the tendency to nausea and 
vomiting if the stomach contains much food. There can be no 
doubt that many of the cases that are called " cramp," and which 
frequently result in drowning, are due to this cause.^ 

Cramps of the various muscles sometimes occur, rendering 
the bather helpless, and if in deep water he is liable to drown 
before assistance can reach him. 

HOW TO RESTORE THE APPARENTLY DROWNED. 

In drowning death takes place by asphyxia. The respira- 
tion is arrested by the submersion of the head, the carbonized 
blood gradually poisons the system, and the heart ceases to beat. 
So long as the heart will react to its appropriate stimulus the 
person may be restored to life. The first thing to do, therefore, 
after a recently-drowned person is taken out of the water, is to 
attempt to re-establish the arrested respiration. Several methods 
are in use for this purpose. Sylvester's is one of the simplest. 
It is as follows : — 

1 So far as the author is aware, Dr. John Morris, of Baltimore, first called especial atten- 
tion to this source of danger. 



HOW TO RESTORE THE APPARENTLY DROWNED. 271 

The body being placed on the back (either on a flat sur- 
face or, better, on a plane inclined a little from the feet upward), 
a firm cushion or similar support (a coat rolled up will answer) 
should be placed under the shoulders, the head being kept in a 
line with the trunk. The tongue should be drawn forward to 
raise the epiglottis and uncover the windpipe. The arms should 
be grasped just above the elbows and drawn upward until they 
nearly meet above the head, and then at once lowered and re- 
placed at the side. This should be immediately followed by 
pressure with both hands upon the belly, just below the breast- 
bone. The process is to be repeated fifteen to eighteen times a 
minute. 

Several years since the Michigan State Board of Health 
published a method which is comprehensive, efiective, easily 
understood, and readily carried out. This method has also been 
adopted by the United States Life-Saving Service. The follow- 
ing are the details of the Michigan method: — 

Rule 1, — Remove all the obstructions to breathing. In- 
stanily loosen or cut apart all neck- and waist- bands ; turn the 
patient on his face, with the head down hill ; stand astride the 
hips with your face toward his head, and, locking your fingers 
together under his belly, raise the body as high as you can with- 
out lifting the forehead off the ground, and give the body a 
smart jerk to remove mucus from the throat and water from the 
windpipe, hold the body suspended long enough to slowly count 
one — tiDO — three — four — five^ repeating the jerk more gently 
two or three times. 

Rule 2. — Place the patient on the ground face downward, 
and, maintaining all the while your position astride the body, 
grasp the points of the shoulders by the clothing ; or, if the body is 
naked, thrust your fingers into the armpits, clasping your thumbs 
over the points of the shoulders, and raise the chest as high as 
you can without lifting the head quite off the ground, and hold 
it long enough to slowly count one — tioo — three. Replace him 
on the ground with his forehead on his flexed arm, the neck 



272 TEXT-BOOK OF HYGIENE. 

straightened out, and the mouth and nose free ; place your 
elbows against [the inner surface of] your knees and your hands 
upon the sides of his chest over the lov^er ribs, and press down- 
ward and inward with increasing force long enough to slowly 
count one — two. Then suddenly let go, grasp the shoulders as 
before, and raise the chest ; then press upon the ribs, etc. These 
alternate movements should be repeated ten or fifteen times a 
minute for an hour, at least, unless breathing is restored sooner. 
Use the same regularity as in natural breathing. 

Ride 8. — After breathing has commenced restore the 
ariimal heat. Wrap him in warm blankets, apply bottles of 
hot water, hot bricks, or anything to restore heat. Warm the 
head nearly as fast as the body lest convulsions come on. Rub- 
bing the body with warm cloths or the hands and slapping the 
fleshy parts may assist to restore warmth and the breathing also. 

If the patient can surely swallow, give hot coiFee, tea, milk, 
or a little hot sling. Give spirits sparingly, lest they produce 
depression. 

Place the patient in a warm bed, and give him plenty of 
fresh air. Keep him quiet. 

Beware ! Avoid delay. A moment may turn the scale for 
life or death. Dry ground, shelter, warmth, stimulants, etc., at 
this moment are nothing — artificial breathing is everything — is 
the one remedy — all others are secondary. Do not stop to re- 
move wet clothing. Precious time is wasted, and the patient 
may be fatally chilled by exposure of the naked body, even in 
summer. Give all your attention and efforts to restore breath- 
ing by forcing air into, and out of, the lungs. If the breathing 
has just ceased, a smart slap on the face or a vigorous twist 
of the hair will sometimes start it again, and may be tried inci- 
dentally. Before natural breathing is fully restored, do not let 
the patient lie on his back imless some person holds the tongue 
forward. The tongue by falling back may close the windpipe 
and cause fatal choking. 

Do not give up too soon ; you are working for life. Any 



PUBLIC BATHS. 273 

time within two hours you may be on the very threshold of 
success Avithout there being any sign of it.^ 

PUBLIC BATHS. 

In all large cities and towns provision should be made for 
free public baths, conducted under official supervision, and for 
the especial use and benefit of the poorer classes. General 
cleanliness is not merely a factor in the preservation of the 
pubHc health, but there is good reason to believe that the cause 
of good order and decency would likewise be promoted by 
furnishing the public the means of easily and cheaply keeping 
clean. Several of the larger cities in the country have estab- 
lished public baths upon a limited scale, and these have been 
very popular and have doubtless been of great benefit. The 
author has shown ^ that about five-sixths of the inhabitants of 
the large cities in the United States have no facilities for bathing 
except such as are afforded by a pail of water and sponge, or 
in summer the proximity of some body of water easily 
accessible. 

1 Report of Michigan State Board of Health, 1874, pp. 91-99. 

2 Address in State Medicine, Journal American Medical Association, July 2, 1887. 



18 



CHAPTEE XV. 

Clothing. 

The primary object of clothing is the protection of the 
:body against the injurious influences of heat, cold, and moist- 
ure. Secondarily, the moral sense of civilized communities 
demands that the nude human body shall not be exposed in 
public. Hence, there are moral as well as sanitary reasons for 
the wearing of clothing ; only the latter can be considered in 
this place. 

Bodies radiate or absorb heat accordingly as they are sur- 
rounded by a medium having a lower or higher temperature 
than themselves. In order, therefore, to avoid chilling of the 
human body, if exposed to a temperature below 37° C. (98° F.), 
clothing must be worn to prevent or retard radiation of the 
body-heat. Exposure of the unprotected body to a low tem- 
perature would not merely cause chilling of the surface, owing 
to the rapid loss of heat, but would incidentally produce con- 
gestion of internal organs by causing constriction of the super- 
ficial capillaries. 

Clothing is also worn as a protection against great heat. 
The head^ especially, needs protection from the sun's rays. 

CLOTHING MATERIALS. 

The materials from which clothing is made are, princi- 
pally, cotton, linen, wool, silk, and the skins of animals. Of 
these, probably the most universally used is cotton. It is cheap, 
durable, does not shrink when wet, absorbs little w^ater, and 
conducts heat readily. It is therefore especially valuable for 
summer garments, allowing rapid dissipation of tlie body-heat 
and evaporation of the perspiration. 

Linen conducts heat even better than cotton, and is for 

(275) 



276 TEXT-BOOK OF HYGIENE. 

this reason largely used for summer clothing. Its principal 
advantage over cotton is that it is more durable and less harsh 
to the skin. 

Wool absorbs water readily and is a bad conductor of heat. 
It is therefore valuable as a w^inter garment, retarding radiation 
from the body. Woolen undergarments should be worn at all 
seasons, in order to preVent too rapid changes of the surface, 
and so invoking diseases depending upon chilling of the body. 
Clothing of pure wool (flannels) is liable to irritate the skin 
of some persons. A mixture of wool and cotton, known as 
" Saxony wool," is softer and less irritating, and makes a serv- 
iceable substitute for pure wool. 

Silk is often used for undergarments. It is light, soft, and 
a bad conductor of heat. 

The skins of animals, with the fur on, are often used for 
outside clothing. They furnish great protection against severe 
cold. The skin is impermeable to wind and rain, while the 
thick, pilous covering of fur retards to a very great degree the 
radiation of heat. In British America, the Northwestern 
States and Territories, and in the Arctic regions, the use of skin 
clothing is necessary for comfort. 

As a protection against moisture (rain and snow) rubber 
cloth is used for overcoats, etc. While it serves eflectually in 
keeping out the rain, it prevents evaporation of the perspiration, 
increasing the liability to chill, and rendering the person wear- 
ing it very uncomfortable, except in cold weather. 

Leather is used almost exclusively in the manufacture of 
foot-wear. It is sometimes used, however, for other articles of 
clothing, such as coats, trowsers, etc. It furnishes most effective 
protection against cold. 

The color of the clothing is of great importance. Ex- 
posed to the sun, white wool or silk absorb very little more 
heat than linen or cotton, but the same material, of different 
colors, when exposed to the sun's rays, exhibits marked difl*er- 
ences in absorptive capacity. The following table shows the 



CLOTHING. 



277 



results of some experiments of Pettenkofer. The material used 



was cotton shirting of the colors named : — 

White absorbed . 

Light Sulphur Yellow absorbed 

Dark Yellow absorbed 

Light Green absorbed 

Turkey Red absorbed 

Dark Green absorbed 

Light Blue absorbed . 

Black absorbed . 



100 heat units. 

102 " '' 

140 " " 

155 " " 

165 " " 

168 " " 

198 " 

208 " " 



When protected from the sun's rays, however, the material 
becomes important and the color is of little consequence. Wool, 
being a bad conductor of heat, retards radiation from the body, 
and is hence the best material for winter clothing. 

Gases and vapors, probably also disease-germs, are ab- 
sorbed by clothing, and may be thus conveyed from place to 
place. It has been found that woolen clothing possesses this 
power of absoi'ption to a much greater degree than linen or 
cotton. The bad odor of a crowded room or of tobacco-smoke 
frequently clings to woolen garments for days, although they 
may be exposed constantly to the air during the interval. It 
would be advisable, therefore, that physicians attending infec- 
tious diseases, hospital attendants and nurses, should wear linen 
or cotton clothing instead of woolen. 

Clothing should be made to fit properly. It should not 
restrain muscular movements, obstruct the circulation, or com- 
press organs. Hence, corsets, belts, and garters are to be con- 
demned. It is a fact of common observation that moderately 
loose clothing is warmer than close-fitting. 

Especial attention should be given to the shape and fitting 
of foot-wear. Boots and shoes are usually made with little 
regard to the physiological anatomy of the foot, and as a result 
the feet of most Americans are deformed, beauty and usefulness 
being in a great degree sacrificed to the Moloch of fashion.^ 

^ See a practical paper by Dr. Benj. Lee, A Shoe That Will Not Pinch, in Sanitarian for 
June, 1884, p. 493. 



278 TEXT-BOOK OF HYGIENE. 

Dyes used for coloring fabrics are sometimes poisonous. 
The author has repeatedly seen troublesome eruptions, and even 
ulcerations of the legs, from wearing stockings dyed with aniline 
compounds. 

By appropriate treatment clothing can be made non- 
inflammable. Tungstate and phosphate of soda are used to 
reduce the inflammability of fabrics. The addition of 20 per 
cent, of tungstate of soda and 3 per cent, of phosphate of soda 
to the starch-sizing used for stiflening linen is eflective. The 
material is not injured by it, and a smooth surface and polish 
can be obtained under the hot iron. Prof Kedzie has recom- 
mended borax for the same purpose. He says : " The simplest 
and easiest way to make your cotton and linen fabrics safe from 
taking fire is to dissolve a heaped teaspoonful of powdered borax 
in \ pint of starch solution. It does not injure the fabric, 
imparts no disagreeable odor, and interferes in no way with the 
subsequent washing of the goods. It does not prevent the 
formation of a smooth and polished surface in the process of 
ironing. Borax can be found in every village, and is within 
the reach of all. It is a cheap salt, and its use for this purpose 
is very simple."^ 

[The following works may also be studied to advantage: — 
Hammond, H3^giene, p. 579. — L. Meyer, Kleidung, in Realenc3'clo- 

paedie d. ges. Heilk., Bd. VII, p. 446. — Yan Harlingen, Care of the Person, 

in Buck's Hygiene and Public Health, vol. i.] 

» Michigan State Board of Health, p. 181. 1880. 



CHAPTER XVI. 

Disposal of the Dead. 

When life is extinct in the animal body decomposition 
begins. This may be either putrefactive or non-putrefactive. 
The difference between the two processes has been explained by 
Liebig. In putrefaction of organic matters only the elements 
of water take part in the formation of the new compounds which 
result, while in non-putrefactive decomposition or decay the 
oxygen of the air plays an important part. Putrefaction can go 
on under water, while decay can only take place when the 
supply of free oxygen is abundant. 

The prompt removal of the bodies of the dead from the 
immediate vicinity of the living is a matter of prime sanitary 
importance. If death results from a contagious or an infectious 
disease, the necessity for the removal of the corpse is evident. 
But, even where there is no danger of propagation of infectious 
disease, the products of putrefaction and decay may give rise to 
serious derangements of health if allowed to pollute the air. 

The chief methods of disposal of the dead are burial in the 
earth, entombment in vaults, and cremation. 

INTERMENT. 

The most common method of sepulture is burial in the 
earth. The corpse is usually inclosed in a case (coffin) of wood 
or metal, and buried from 1 to 2 metres deep. Here decom- 
position sets in, which is at first putrefactive and later on non- 
putrefactive. In the course of several years, from five to ten, 
the entire body, with the exception of the bones, has usually 
disappeared and become converted into a dry mold. 

The soil of a burial-ground should be dry and porous, so 

(279) 



280 



TEXT-BOOK OF HYGIENE. 



as to be easily permeated by the air. In a sandy or gravelly 
soil the decay of a corpse is much more rapid than in a moist, 
clayey soil. In the latter the bodies more readily undergo 
putrefaction, or become converted into a substance termed adi- 
pocere. It has been calculated that in a gravelly soil the decay 
of a corpse advances as much in one year as it would in sand in 
one and two-thirds, and in clay in two to two and one-third 
years. The decay of the dead bodies is principally (if not 
entirely) dependent upon the presence of living vegetable organ- 
isms. If the access of free oxygen is prevented, the bacteria 
of putrefaction will thrive and cause putridity. If, however, 
the soil is loose, porous, and easily permeable by the air, the 
bacteria of decay will be present and produce their charac- 
teristic effects. 

The barometric pressure seems to affect the decomposition 
of dead bodies. For example, at the refuge of St. Bernard, in 
the high Alps, the bodies of those dying are not buried, but 
exposed to the air, where they undergo a drying, shrinking, and 
mummification instead of putrefaction or decay. 

Alternate saturation and drying of the soil promotes the 
rapidity of decay. 

Certain occupations are said to produce changes in the 
tissues which resist decay. Thus, tanners are supposed to resist 
the final changes of the tissues longer than persons of other 
occupations. Shakespeare makes the grave-digger in Hamlet 
say: "A tanner will last you nine years." The corpses of those 
poisoned by phosphorus, arsenic, sulphuric acid, or corrosive 
sublimate also decay more slowly than those of cases of infectious 
diseases. 

All the tissues may be converted into adipocere, but in the 
large majority of cases only the fat and connective tissue undergo 



this change. 



SUPPOSED DANGERS OF BURIAL-GROUNDS. 



Popular sanitary literature teems with supposed instances 
of the injurious influences of cemeteries upon the health of 



SUPPOSED DANGERS OF BURIAL-GROUNDS. 281 

persons living in their vicinity. An unprejudiced consideration 
of the subject shows, however, that there is no trustworthy evi- 
dence that any of the gases exhaled by decaying or putrefying 
bodies are injurious to health. The air of closed burial-vaults 
may be dangerous from the large proportion of carbon dioxide 
contained in it, but the other gaseous products of decomposition 
have no deleterious effects. The dangers to health from the 
proximity of cemeteries are doubtless very much exaggerated. 
Pettenkofer and Erismann have shown that a single large privy- 
vault, containing about 17 cubic metres of excrement, gives off 
nearly as large an amount of putrefactive gases in the course 
of one year as is exhaled by a burial-ground containing 656 
decomposing corpses in ten years. 

Where bodies are properly buried, and the ground is not 
overcharged by corpses, it is not probable that infectious diseases 
are propagated from interred bodies. There are no facts on 
record which show that such an event has occurred. 

The dangers of pollution of water by cemeteries have also 
been much overestimated. The purifying power of soil-strata, 
through which the water is compelled to percolate before reach- 
ing the well after becoming charged with the products of decom- 
position, is in most cases sufficient to remove all deleterious 
matters. 

Cemeteries should not be located within a city, but must 
be easily accessible. The soil should be dry gravel or sand, 
with a low ground- water level. The graves need not be deeper 
than 1^ metres to the top of the coffin. 

ENTOMBMENT IN VAULTS. 

Burial-vaults in churches or in the open air should be 
discountenanced. The gases of decomposition are given off 
directly to the air without the modifying power of the soil, and 
often constitute a nuisance, even if not deleterious to health. 
Entombment in vaults or crypts has not a single favorable 
circumstance to recommend it. 



282 TEXT-BOOK OF HYGIENE. 

CREMATION. 

Within recent years the rapid incineration of the dead in 
properly-constructed furnaces has been frequently recommended. 
In the United States a cremation furnace was built several years 
ago at Washington, Pa., by the late Dr. J. C. LeMoine. Among , 
the remains of those cremated were those of the late Dr. Samuel 
D. Gross, the distinguished surgeon. The practice has not 
gained very many adherents, however, although cremation 
societies have been organized and furnaces built in several of 
the cities throughout the country. Aside from the objections 
urged by the more conservative classes, who desire to adhere to 
the time-honored custom of interment, serious legal objections 
have been brought forward. In cases where poisoning is 
suspected some time after death, the cremation furnace would 
have destroyed every evidence of crime, and conviction of a 
criminal poisoner could not be obtained. 

The real advantages of cremation, such as rapid destruction 
of a corpse, economy of space in keeping the remains, and 
avoidance of pollution of the soil by decaying bodies, and pos- 
sible pollution of air and water, are more than counterbalanced 
by the expense and the medico-legal objection mentioned. From 
a sanitary point of view, cremation is not necessary in this 
country. A proper regulation of cemeteries will prevent any 
possible dangers to the living from pollution of the air, soil, or 
waterby the decaying remains of human beings. 

INTERMENT ON THE BATTLE-FIELD. 

After battles, the disposal of the bodies of the slain is 
often a serious problem. Naegeh proposes the following method 
of interment : After selecting the place of burial, the sod and 
layer of humus are removed from a sufficiently large surface and 
thrown to one side. The corpses are then laid upon the denuded 
place, and the layers of corpses separated by sand, gravel, or 
fine brush-wood. A trench is then dug around the pile of dead 
and the soil gained is thrown over the corpses until they are 



INTERMENT ON THE BATTLE-FIELD. 283 

covered to a depth of 1 metre, when the humus and sod are 
placed over the whole. This furnishes a dry grave in which 
decay rapidly takes the place of putrefaction, and the corpses 
soon molder away. The same procedure may be followed in 
cases of epidemics where the number of deaths is too great to 
properly bury them in single graves. 



!! 



CHAPTEE XYII. 

The Gerai Theory of Disease. 

The ruling doctrine in the pathology of the present day is 
the germ theory of disease. Based upon the doctrine of omne 
vivum ex vivo, and supported by strong experimental and clinical 
evidence, it is accepted by the great majority of physicians. Its 
advocates claim that the large class of diseases known as con- 
tagious or infectious are all due to the presence in the blood or 
tissues of minute organisms, either animal or vegetable. Many 
other diseases, not at present included in the above class by 
general pathologists, are also believed, by the adherents of the 
germ theory, to be caused in the same way. The following con- 
stitutes a brief review of the most prominent facts in the history 
of the doctrine : — 

The doctrine of the vital nature of the contagium of dis- 
ease — the contagium animatum of the older writers — w^as held 
in a vague way by many of the physicians of the past, but it was 
not until the latter part of the last century that the theory took 
definite shape. In the works of Hufeland, Kircher, and Linne 
the idea is expressed with more or less directness that the propa- 
gation of infectious diseases depends upon the implantation of 
minute independent organisms into or upon the affected indi- 
vidual. This hypothesis was, however, first clearly enunciated 
and defended with great force by Henle in 1840. Three years 
earlier, Cagniard de la Tour and Schwann had established a 
rational basis for the theory by their observations upon the yeast- 
plant and its relation to fermentation. In 1835 Bassi had dis- 
covered in the bodies of silk -worms affected by muscardine^ a 
disease of these insects which proved very destructive, a para- 
site which w^as soon shown to be the cause of the disease. 
Within the next few years, Tulasne, DeBary, and Kuehn 

(285) 



286 TEXT-BOOK OF HYGIENE. | 

proved that certain fungi were the causes of the potato-rot and 
other diseases of plants. Schoenlein, Malmsten, and Gruby, 
between 1840 and 1845, demonstrated that those skin diseases 
of man classed as the tinece were due entirely to the action of 
vegetable parasitic organisms. 

Up to this time the germ theory, as now accepted, had 
received no support from experiments. All the diseases claimed 
as parasitic were purely local ; so far as the parasitic nature of 
the general diseases was concerned, all was hypothetical. In 
1849, Guerin Meneville discovered a corpuscular organism in 
the blood of silk-worms affected by the pehrine^ which was later 
proven by Pasteur to be the true cause of this destructive dis- 
ease. Pollender, in 1855, and Brauell, in 1857, found numer- 
ous minute rod-like organisms (bacteria) in the blood of animals 
dead from splenic fever. In 1863 Davaine investigated the 
subject more fully, and showed beyond doubt that the little 
organisms discovered by Pollender were the true cause of splenic 
fever, or anthrax. The more recent researches of Eobert Koch 
upon the history of these bacteria or bacilli of splenic fever 
have removed all doubt of their etiological significance. 

In 1883 the last-named observer startled the medical world 
by the assertion that consumption or tuberculosis was a disease 
of microbic origin, and dependent upon the presence, in the 
affected tissues, of an organism which he named bacillus tuber- 
culosis. Much controversy arose upon this point, but Koch 
fortified his position so strongly with proofs, both experimental 
and clinical, that it may now be regarded as fully demonstrated. 
Koch has likewise shown (1885) that Asiatic cholera is due to 
a bacterial organism, termed by him the " comma bacillus," 
from its shape. It is generally regarded by bacteriologists, how- 
ever, to belong to the class of organisms known as spirilla, and 
not to the bacilli. Eberth discovered the bacillus which is now 
generally accepted as the cause of typhoid in 1880; Fehleisen, 
the micrococcus of er3^sipelas in 1883; Obermeier, the spirillum 
of relapsing fever in 1868; Schutz and Loffler discovered the 



THE GERM THEORY OF DISEASE. 287 

bacillus of glanders in 1882; Neisser announced the discovery 
of the micrococcus of gonorrhoea in 1879. The bacillus of 
leprosy was discovered by Hansen in 1879, The micro-organ- 
isms of malaria (oscillaria malariae), which are believed to be 
animal organisms, were discovered by Laveran in 1881. This 
organism is different from the bacillus malar ice of Klebs and 
Tommasi-Crudeli, which most pathologists do not regard as pos- 
sessing any pathological significance. Pneumonia may also be 
regarded as a microbic disease, since the demonstrations of 
Sternberg, Weichselbaum, and Frankel of the constant presence 
of the micrococcus Pasteurii in the sputa in that disease. 

The careful observations and researches of the investigators 
mentioned, as well as of many others who have worked earn- 
estly in this field, have established the germ theory of disease 
upon a secure foundation. For the diseases mentioned the 
parasitic origin may be accepted as fully proven. For a number 
of others, among which may be mentioned small-pox, yellow fever, 
diphtheria, scarlet fever, typhus fever, measles, hydrophobia, etc., 
the etiological connection between the disease and certain hypo- 
thetical organisms not yet discovered appears probable. 

In connection with the germ theory there has arisen of late 
a very important question in its bearing upon preventive medi- 
cine. This is the value of the so-called protective inoculations 
against infectious diseases. The protective influence of vacci- 
nation against small-pox is firmly established by indubitable 
evidence. Within the last three or four years a procedure in- 
troduced by Pasteur to protect animals against certain fatal in- 
fectious diseases, such as splenic fever, fowl-cholera, and rabies, 
has claimed much attention. Pasteur's observations were first 
made upon the disease termed chicken-cholera. He found that 
the blood of the dead fowls, or of those attacked by the disease, 
swarmed with bacteria. Inoculation of healthy fowls with this 
diseased blood, or with the bacteria alone, carefully freed from 
all animal fluids, produced the same disease. The bacteria 
were therefore assumed to be the cause of the disease. The 



288 TEXT-BOOK OF HYGIENE. 

investigator then took a quantity of these bacteria and " culti- 
vated " them through a number of generations, using sterihzed 
chicken-broth as a culture medium. Fowls inoculated with the 
result of the last cultivation were still attacked by the same 
symptoms, but in a very mild degree, and almost uniformly 
recovered from the disease. On subsequent inoculation with 
infected blood no effect was produced upon the " vaccinated " 
fowls, wliile the same blood introduced into fowls not '' pro- 
tected " by the previous inoculation produced its customary 
flital ctfcct. Pasteur and others repeated these experiments 
with the organisms found in the blood in splenic fever and 
obtained similar results. Inoculations made with cultivations 
from the spinal cord of animals suffering from rabies have also 
been claimed as protective against this disease and hydrophobia. 
These protective inoculations have been made upon large num- 
bers of sheep and cattle within the past three years, and with 
very remarkable success. Eecently, however, it has been shown 
that the protection afforded by the inoculation is a very tem- 
porary one, and that after a variable but brief interval the pro- 
tected animals ai'e again liable to be fatally attacked by the 
disease. The opinion seems to be justified that cultivation pro- 
duces only a temporary degeneration of the bacteria, which 
rapidly disappears when the organisms are again brought in 
relation with their proper nutritive fluid. The " protective in- 
oculations " produce a mild attack of the disease, which is for a 
time a bar against a second attack; but the effect soon wears off, 
leaving the animal in its pristine condition of receptivity toward 
the infective material. 

[Tlie following works on this subject are recommended to 

the student : — 

Sternberg and Magnin, The Bacteria; second edition. — Fluegge, 
Fermente und Mikroparasiten, in von Pettenkoffer und Ziemssen's 
Handbuch d. Hygiene.] 



CHAPTER XVIII. 

Contagion and Infection. 

The adjectives "contagious" and "infectious" are used to 
designate certain diseases which are propagated by immediate 
contact, or through the intervention of some other medium, from 
the sick to the healthy. The matters in which reside the mor- 
bific power are now behoved by many to be vegetable organisms, 
but not a few pathologists hold to the view that the real con- 
tagia, or disease-bearing agents, are modified animal cells or 
abnormal fluids. 

The differentiation between contagion and infection is not 
easy. Many of the diseases commonly called contagious are 
also infectious; that is, they are propagated not merely by direct 
contact, but also by air, water, or food which may have become 
infected with the morbific agents. Syphilis, for example, may 
be regarded as simply a contagious disease ; at the present day, 
at least, we cannot conceive syphilis to be propagated by breath- 
ing infected air or drinking water contaminated with the poison 
of syphilis. Cholera, typhoid, and yellow fevers, on the other 
hand, are examples of infectious diseases, neither of them being 
directly contagious, but conveyed from sick to well through the 
medium of contaminated air, water, or food. Between these 
two stand small-pox and typhus fever (and perhaps the other 
exanthemata), which are not merely contagious, but infectious 
also. 

There is still a third class of acute diseases not properly 
included in either of the classes mentioned. This is the class of 
miasmatic diseases, of which malarial fevers are the type. Ac- 
cording to recent observations, pneumonia ought, perhaps, to 
come in this class. 

The contagious and infectious diseases are of particular 

^' (289) 



290 TEXT-BOOK OF HTGIEXE. 

interest to sanitarians, because it is believed that by judicious 
earning out of sanitary measures they can be prevented. Hence 
they are sometimes termed preventable diseases. Another pecu- 
liarity of the infectious diseases is that they usually occur in 
groups of cases. Thus, small-pox, measles, scarlet fever, typhus 
fever, diphtheria, and others of the class do not occur sporadi- 
cally, as it is termed ; that is to say, it rarely happens that only 
one case of small-pox is observed in a locality, unless active 
measures are at once taken to stamp it out. Usually a number 
of cases occur successively, and in most instances the succeeding: 
cases can be traced ultimately to the first case. 

Contagious and infectious diseases frequently appear as 
epidemics. Authorities differ as to the proper definition of an 
epidemic; that is, given the population of a place, how many 
cases of an infectious or contagious disease are necessary before 
the disease can be considered epidemic at such place. The 
following formid.a was given by the Xew Orleans Medical and 
Surgical Association in response to the query, " Under what cir- 
cumstances is it proper to declare such diseases (diphtheiia, 
scarlet fever, measles, small-pox, yellow fever, etc.) epidemic in 
a place ] '"' The answer given is that the disease should be 
declared epidemic when the number of cases should reach these 
proportions^ : — 



a population 


of 


100 . 


5 per cent. 


.. 


■' 


5i)0 


A " " 


it u 


u 


2.000 to 5.000 . 


22J •' thousand. 


<£ U 


u 


6.000 to 10.000 . 


16" " 


it U 


it 


20,000 to 5C.000 . 


8 " ten thousand 


i( u 


a 


50.000 to 100.000 


^ i( u u 


4i U 


u 


200.000 . 


1 U U (( 



A disease is said to be pandemic when it spreads rapidly 
over a sreat extent of country, and endemic when it is constantly 
present in a place. Diseases which may be prevalent in certain 
localities, i.e., endemic, not infrequently spread over larger areas 



» Public Health, vol. ri, pp. 416, 417 



COXTAGIOX AXD IXFECTIOX. 



291 



of country, — overflow their borders, as it were, — and become epi- 
demic or pandemic. Thus cholera, which is endemic in certain 
districts of India, frequently spreads over adjacent tenitoiy, and 
at times the epidemic wave, as it has been called, rolls over 
nearly the whole world. Plague, malarial and yellow fevers 
make similar epidemic excursions into other countries, or sec- 
tions of country, at a distance from the places where they are 
endemic. 

Contagious and infectious diseases possess another peculi- 
arity in that a certain time is required after the introduction of 
the poison into the system before the disease manifests itself by 
its typical symptoms. This is called the "stage of incubation," 
and varies for different diseases. The following table shows the 
stage of incubation of a number of such diseases : — 





Taele X\TI. 






LN-CLEATIOX OF IXFECnOUS DI 


5EASES. 


Measles 


10 days 


Small-pox, 
Mumps, . 
Diphtheria, 
Scarlet fever, . 












12 - 

18 " 
3 ■• 
3 " 


Whooping-cough. 
Typhoid fever. . 
Typhus fever, . 
Chicken-pox, . 












14 " 

14 •• 

1 to 2 '• 

4 " 


Erysipelas, 

m ■ T T ■ 


1 • 


1 ^^ 




/>_ _^' 




4 " 



The period during which the infectiveness of the patient 
lasts also varies. In some cases it probably depends upon the 
measures taken to prevent the spread of the disease, e.g.. disin- 
fection of the patient and liis surroundings. 



CHAPTEE XIX. 

History of Epidemic Diseases. 

An important part of the knowledge of the sanitarian is 
that which relates to the history of the great epidemic diseases 
which have at various periods devastated large areas of the in- 
habited world. In this chapter the history of these diseases will 
be briefly traced. Although some of these diseases have nearly 
or quite ceased, a knowledge of their habits and of the causes 
that finally led to their extinction is of great value, for the reason 
that the principles and measures of prevention which were 
effective in times past are the same which must apply at pres- 
ent and in the future. Hence, time spent in looking back over 
the fields traversed and noting victories won will not be wasted. 

The epidemic diseases which will here claim attention are 
the Oriental plague, the sweating sickness, small-pox, Asiatic 
cholera ; typhus, typhoid, scarlet, relapsing, and yellow fevers ; 
diphtheria, dengue, epidemic influenza, and syphilis. In addi- 
tion, some information will be given on certain of the diseases 
of animals transmissible to man. Among these are sheep-pock, 
actinomycosis, bovine tuberculosis (perlsucht), rabies, anthrax 
(milzbrand), and glanders. 

THE ORIENTAL PLAGUE. 

The Oriental plague, bubonic plague, the black death, or 
simply the " plague," or great pestilence, overtopping in its 
fatality all other pestilences, is mentioned by a number of the 
Greek and Latin medical authors. The first account which 
clearly refers only to this disease is given by Procopius. Ac- 
cording to this and other contemporary authors, the disease be- 
gan to spread in the year 542 from Lower Egypt, passing in one 
direction along the coast of Northern Africa, and in the other 

(293) 



294 TEXT-BOOK OF HYGIENE. 

invading Europe by way of Syria and Palestine. In the course 
of the succeeding years this pandemic reached " the limits of the 
inhabited earth," in the language of the writers of the day. The 
disease prevailed about half a century, and produced the greatest 
devastation wherever it appeared. " Cities were devastated, the 
country converted into a desert, and the wild beasts found an 
asylum in the abandoned haunts of man." ^ 

The plague is an acute infectious disease, which is char- 
acterized by an affection of the lymphatic system, i.e., inflam- 
mation and swelling of the external and internal lymphatic 
glands. Accessory symptoms are petechial spots upon the skin, 
and haemorrhages from various organs, as the stomach, nose, 
kidneys, rectum, and uterus. Those attacked suffer in varied 
degrees of intensity. In some, a fulminant form occurs which 
carries off the patient within three days ; there is another class 
of cases in which buboes develop, with accompanying fever and 
haemorrliages ; and, finally, a light form, rarely fatal, in which 
only the local symptoms are manifested. In the great pan- 
demic of the plague in the fourteenth century cough and bloody 
expectorations were very frequent. In the later epidemics 
haemorrhage from the lungs has been rarely noticed as a symptom. 

About the middle of the fourteenth century the bubonic 
plague made a second incursion into Europe from its home in 
the East. A most graphic description of its ravages is given by 
Boccaccio in the " Decameron." This author states that in 1359, 
" between March and July following, according to authentic 
reckonings, upward of 100,000 souls perished in the city 
(Florence) ; whereas, before that calamity it was not supposed 
to contain so many inhabitants." 

This terrible epidemic was forcibly characterized by its com- 
mon name, " the black death." Hecker estimates that during its 
continuance, from 1347 to 1351, 25,000,000— one-fourth of the 
probable total population of Europe — died. In various cities 
the mortality was — in London, 100,000; in Paris, 50,000; in 

» "Warnefried, quoted by Hirsch, Hist-Geographische Pathologie, I, p. 350. 



THE ORIENTAL PLAGUE. 295 

Venice, 100,000 ; in Avignon, 60,000 ; in Marseilles, 16,000, in 
one month. It was said that in all England scarcely a tenth 
part of the population escaped death from the disease. 

The moral effects of this great pandemic of the plague were 
hardly less deplorable than the physical. Religious fanaticism 
held full sway throughout Europe, finding its yent in all manner 
of excesses. The so-called Brotherhood of the Cross, otherwise 
known as the Order of Flagellants, which had arisen in the 
thirteenth century, but had been suppressed by the ecclesiastical 
authorities, was reyiyed during the black pestilence, and large 
numbers of these religious enthusiasts roamed through the 
various countries on their great pilgrimages. Their power in- 
creased to such a degree that Church and State were forced to 
combine for their suppression. One consequence of this fanat- 
ical frenzy was the persecution of the Jews. These were accused 
of being the cause of every evil that befell mankind, and many 
were put to death. 

In the fifteenth and sixteenth centuries the plague \yas 
generally diffused throughout Europe, and in the second third 
of the seventeenth century its final incursion into the Occident 
took place. The great epidemic in London, so graphically de- 
scribed by Defoe,^ occurred in 1665. In the early part of the 
eighteenth century (1720) the plague visited Marseilles and 
Toulon ; from 1769 to 1772 it was epidemic in Moldavia, Wal- 
lachia, Poland, and Southern Russia ; near the close of the last, 
and again in the beginning of the present century, in Transyl- 
vania, Wallachia, Southern Russia, and Greece. Very recently, 
in 1878 and 1879, and again in 1885, the plague threatened a 
new irruption into European territory, being epidemic in the 
district of Astrachan, on the Caspian Sea. 

Although the bubonic plague has never been observed in 
America, and has spared Europe almost entirely during the present 
century, it still persists in certain countries of Asia and Africa, 
especially in Arabia, Mesopotamia, Persia, and the coast of Tripoli. 

* Journal of the Plague in London. 



296 TEXT-BOOK OF HYGIENE. 

The older authors ascribed the origin of the plague to 
various real or supposed conditions. Comets, conjunctions of 
the planets, " God's just punishment for our sins," and similar 
causes were advanced to account for the outbreaks. Most of the 
writers of the post-mediaeval and modern epochs ascribed the 
disease to meteorological conditions. Observing the fact that the 
plague never advanced into the torrid zone, and that an epidemic 
generally ended with the advent of hot weather, a high tempera- 
ture was believed to be incompatible with the existence of an 
epidemic, and a cold or temperate climate was considered neces- 
sary to an outbreak of the disease. The exceptions to the rule 
are so numerous, however, that the theory of the climatic or 
meteorological origin of the plague failed of support. The theory 
which ascribed the origin of the epidemics to the influence of 
certain hot and dry winds or a high humidity is also insufficient. 
Certain geological formations have been supposed to furnish 
favorable conditions for the development of the disease. Facts 
show, however, that the disease has prevailed epidemically and 
endemically in various parts of the earth, and of the most diverse 
geological character. A certain elevation above sea-level has 
been held to confer immunity, but recent observations in India 
show that this belief is unfounded, even places at an elevation 
of 10,000 feet above sea-level giving no security against attack. 

There is, however, one point upon which nearly all writers 
who mention the fact at all agree. This is that had liygienic 
conditions are always present where plague prevails. Nearly all 
observers who have left their impressions on record mention the 
accumulation of filth in the houses and streets, deficient removal 
of excrementitious and other sewage matters, crowding and im- 
perfect ventilation of dwellings as causes favoring the develop- 
ment and spread of the pestilence. All point out the necessity 
of the removal of these evils as the most important prophylactic 
measure to be adopted, and all of them call attention to the fact 
that those classes of the popiilation most exposed to these unfa- 
vorable influences suffer most from the violence of the epidemic. 



THE ORIENTAL PLAG^^E. 297 

The later reports of the epidemics in Persia, India, Mesopo- 
tamia, and Hussia agree in asserting that nothing seems to have 
promoted the epidemic and endemic prevalence of the plague so 
much as the material wretchedness of the inhabitants of those 
countries. In a collection of papers on the plague, printed by 
a British Parliamentary Commission m 1879, occur these state- 
ments : " The filth is everywhere," says Mr. Pennie, one of the 
reporters, — " in their villages, their houses, and their persons. 
Their dwellings are generally low and ill- ventilated, except 
through their bad construction ; and the advantage of the 
natives in other parts of India, of living in the open air, is lost 
to the villagers of Ghurwal, from tlie necessity of their crowding 
together for mutual warmth and shelter against the inclemency 
of the weather." Dr. Dickson, reporting on the plague in Irak 
Arabi in 1876, says: " The most palpable and evident of all the 
causes which predispose an individual to an attack of plague 
during an epidemic outbreak is jpoveiiy. No other malady shows 
the influence of this factor in so striking a degree ; so much so, 
indeed, that Dr. Cabiadis styles the plague miserice morhis. In 
his experience (1876-77, in Bagdad) he found that the poor 
were seldom spared, the wealthy hardly ever attacked." ^ 

The manner of the transmission of the plague is generally 
by prolonged inhalation of an infected atmosphere. Hence, it 
may be termed an infectious disease, although it is not improbable 
that it may be communicated by direct contact both of persons 
and of fomites. It is probably due to a micro-organism, although 
no demonstration of the latter has been furnished up to the 
present time. 

These considerations indicate the measures of prevention 
to be adopted. They consist of a rigid quarantine of persons 
and fomites, prompt and complete isolation of infected individuals 
and localities, and destruction (by fire) or thorough disinfection 
by steam or sulphurous-acid gas of all materials capable of con- 
veying the virus of the disease. 

» Hirsch, op. cit., p. 370. 



298 TEXT-BOOK OF HYGIENE. 

THE SWEATING SICKNESS. 

This name concisely characterizes an epidemic disease 
which for the first time appeared in the city of London and 
otlier parts of England in the antnmn of l-iSo. According to 
Lord Bacon/ the disease began about the 21st of September 
and lasted until near the end of October. It broke out a second 
time in the summer of 1507; a third time in July, 1518, spread- 
ing in the course of six months throughout England. In ^lay, 
1529, the disease made its appearance again in the latter country, 
spreading thence over a great part of the continent of Europe. 
Another very malignant epidemic broke out in the spring of 
1541, lasting through the summer, and limited in its ravages to 
England. 

With this last outbreak, in 1551, this disease disappeared 
entirely in England and has not re-appeared there up to the 
present day. In the beginning of the eighteenth century, how- 
ever, a disease very similar in its symptoms and course broke out 
in Picardy and other districts of Northern France, being confined 
for a number of years to this section of the country. Toward 
the end of the century it spread to the south of France, and 
since that time has appeared epidemically at intervals, 195 dis- 
tinct outbreaks having been observed in the course of 168 years, 
from 1718 to 1887. The disease has frequently appeared in Italy 
since 1755, and in various parts of Germany since 1801. In 
Belgium it has been observed at a few places within the present 
century. 

The disease appeared suddenly, ofl:en at night-time. The 
patient was attacked with palpitation of the heart, dyspnoea, 
great anxiety and oppression, and profuse perspiration. A 
miliary eruption often appeared on the skin. In favorable cases 
these symptoms diminished in the course of one or two days, the 
urinary secretion, which had been suppressed, was restored, and 
the perspiration became gradually less free. Kecoveiy ensued 
ill from one to two Aveeks. In grave cases there were, in the 

» History of Henry VH. 



SMALL-POX. 299 

beginning of the attack, violent headache, dehrium, convulsions, 
followed by a comatose condition, from which the patients rarely 
recovered. 

This disease is undoubtedly of a miasmatic, infectious nature, 
as proved by its rapid spread and limitation to certain localities. 
It appears most frequently in the spring and summer, and is 
nearly always observed in marshy or damp localities. Its spread 
is favored by a high temperature and humidity. There is no 
apparent connection between the outbreaks of the sweating 
sickness and overcrowding or other insanitary conditions ; in 
fact, it is stated by numerous observers, both old and recent, that 
children, the aged, and generally the poorer classes were remark- 
ably exempt from the disease. The recent epidemic in France, 
in 1887, was investigated by Dr. Brouardel, Chantemesse, and 
other epidemiologists, but no trustworthy conclusions as to tlie 
nature of the disease have yet been reached. 

Since the first appearance of Asiatic cholera in France, in 
1832, an apparently intimate connection has been observed 
between the occurrence of that disease and outbreaks of sweating 
sickness. A disease strongly resembling the sweating sickness 
has also been observed in India in- districts contiguous to places 
where cholera was at the time epidemic.^ 

SMALL-POX. 

The earliest details concerning small-pox are derived from 
certain Chinese records, according to which it appears that this 
disease was known in China upward of 2000 years ago. It was 
also known at a very early period in India. It is believed to 
have been introduced into Europe in the second century by a 
Roman army returning from Asia. It is believed that the Em- 
peror Marcus Aurelius died of small-pox, which prevailed in his 
army at the time of his death. 

The first distinct references to small-pox in medical literature 
occur in the writings of Galen, in the second century. Rhazes, 

* Murray, Madras Quart. Med. Joum., 1840-41. Quoted in Hirsch, loc. cit, p. 83. 



300 TEXT-BOOK OF HYGIENE. 

in the ninth century, wrote upon the disease, describing it very; 
accurately. 

The almost universal susceptibility to small-pox caused 
wide-spread devastation wherever it appeared previous to the 
introduction of vaccination. The statement is made that in 
England, in the last century, about one person in every three 
was badly pock-marked. The mortality from the disease was 
exceedingly great, being, in the latter half of the eighteenth 
century, about 3000 per million of inhabitants annually. 

In India the mortality from small-pox has been exceedingly 
great within the last twenty years. From 1866 to 1869, 140,000 
persons died in the Presidencies of Bombay and Calcutta, having 
a population of about 40,000,000. Several years later, from 
1873 to 1876, 700,000 died from this disease. 

China, Japan, Cochin China, the islands of the China Sea, 
and Corea are frequently ravaged by small-pox. In the latter 
country nearly all the inhabitants are said to bear evidence of 
an attack of the disease. 

The Samoyedes, Ostiaks, and other natives of Eastern Siberia 
have frequently suffered from devastating epidemics. In Kamt- 
cliatka the disease was introduced in 1767, and produced 
frightful ravages. Many villages were completely depopulated. 

In Mexico small-pox was introduced by the Spaniards in 
1520. In a short time it carried off over 3,500,000 of the 
natives. In the Marquesas Islands one-fourth of the inhabitants 
have fallen victims to the disease since 1863. 

It was first introduced into the Sandwich Islands in 1853, 
and carried off 8 per cent, of the natives. 

Australia, Tasmania, New Zealand, and the Fejee Archi- 
pelago remain exempt to the present day from small-pox. It has 
several times been carried to Australia by vessels, but has always 
been promptly checked by the vigilance of the authorities. 

On the Western Hemisphere small-pox was unknown before 
the arrival of the European conquerors. It has been spread by 
the whites or imported African slaves to nearly all the Indian 



SMALL-POX. 301 

tribes of both continents. AVlien it attacks large communities 
miprotected by previous outbreaks of the disease, or by inocula- 
tion or vaccination, its ravages are frightful. The mortality of 
unmodified small-pox is usually between 30 and 40 per cent. 

Small-pox is a highly contagious and infectious disease. 
It is produced by actual contact, by inoculation, and by inhaling 
an atmosphere charged with the poison. In order to cause an 
outbreak two factors are necessary : first, a number of individuals 
susceptible to this disease, and, second, the introduction into the 
body, in some manner, of the virus upon which it depends. 

Small-pox is spread from (1) persons sick with the disease; 
(2) others, not themselves sick or susceptible, but coming in 
contact with the poison ; (3) fomites (cotton, wool, etc.), and (4) 
the bodies of persons dead with small-pox. It is also probable 
that the air in the immediate vicinity of a person sick with small- 
pox becomes charged with the poison and able to convey the 
disease. It is at present impossible to fix the distance to which 
this infectiousness of the air extends, but it does not ordinarily 
reach beyond the room in which the patient is confined. 

It is a fact of common observation that the darker races 
are more commonly attacked, and the disease is likewise more 
fatal among them. The mortality among negroes is much larger 
than among other races. 

It is a current belief that small-pox is only contagious after 
the development of the pustules. This is a serious error. It is 
probably contagious in all stages of the disease ; certainly as 
early as the first appearance of the eruption, and probably even 
in the stage of preliminary fever. 

One attack of small-pox usually confers immunity from the 
disease for life. This rule has its exceptions, however, which, if 
not numerous, are yet not infrequent. The author has seen a 
case in which the patient suffered from a third attack of the 
disease. 

The popular belief, that persons suffering from any acute 
or chronic disease are less Hable to be attacked by small-pox 



302 TEXT-BOOK OF HYGIENE. 

than those at the time in good health, is erroneous. On the 
contrary, the subjects of chronic disease, such as consumption or 
dyspepsia, are much more hable to succumb to an attack of 
small-pox than persons previously in good health. 

It is true, however, that individuals suffering from some 
other acute infectious disease, like scarlet fever, measles, typhoid 
fever, etc., are generally, though not absolutely, exempt from 
an attack of small-pox during the time they are sick with such 
disease. But if they are exposed, after recovery, to the small- 
pox infection, their liability to an attack is as great as in those 
who have not passed through a similar disease. A number of 
cases have been reported by Curschmann,^ in which infection 
by small-pox took place on the day in which convalescence from 
typhoid fever was established. 

The author has reported a case^ in which the patient passed 
through an attack of erysipelas during the incubative stage of 
small-pox. From all the evidence attainable, the incubative stage 
w^as not prolonged by the intercurrent erysipelas. 

Epidemics of small-pox usually begin in the autumn or 
winter, and lessen in violence as warmer weather approaches. 
The spread of the disease is slow at first, increasing in rapidity 
as the foci of infection multiply. 

When the poison is imported into a community late in the 
spring or during the summer, the increase in the number of 
cases is exceedingly gradual until colder weather sets in. If it 
is introduced during the winter, the disease spreads much more 
rapidly, but decreases, and sometimes almost disappears, during 
the summer. On the return of cold weather, however, the epi- 
demic starts out with a new lease of activity and presents great 
difficulties to its restriction. 

A number of observers, among whom are Coze and Feltz, 
Lugenbiihl, Weigert, Strauss, Garre, and Wolff, claim to have 
discovered specific organisms in the contents of variolous pustules, 
in the blood of patients with the disease, and in vaccine lymph. 

» Ziemssen's Cyclopaedia, vol. ii. ' Medical News, July 7, 1883. 



SMALL-POX. 303 

Expert bacteriologists are, however, not willing to accept the 
evidence hitherto furnished as conclusive. 

Inoculation. — The prevention or restriction of such a uni- 
versal and fatal pestilence as small-pox is a matter of the deepest 
importance. The first attempt to limit its fatality dates from the 
end of the seventeenth century. It became generally known in 
Europe, about the year 1 700, that the intentional inoculation of 
variolous matter into healthy individuals induced an attack of 
the disease, which generally ran through its various stages with 
less virulence than when the disease was contracted in the usual 
manner. In 1716 and 1717 two papers were published in the 
" Transactions of the Royal Society of England" giving an ac- 
count of the process of inoculation. The attention of the public 
was especially directed to the matter, however, by the famous 
letter of Lady Mary Wortley Montagu, dated April 1,1717. This 
letter is as follows^: "Apropos of distempers, I am going to tell 
you a thing that will make you wish yourself here. The small- 
pox, so fatal and so general amongst us, is here entirely harm- 
less by the invention of ingrafting^ which is the term they give 
it. There is a set of old women who make it their business to 
perform the operation every autumn, in the month of September, 
when the great heat is abated. People send to one another to 
know if any of their family has a mind to have the small- pox ; 
they make parties for this purpose, and when they are met — 
commonly fifteen or sixteen together — the old woman comes 
with a nut-shell full of the matter of the best sort of small-pox, 
and asks what veins you please to have opened. She immediately 
rips open that you ofier to her with a large needle — which gives 
you no more pain than a common scratch — and puts into the 
vein as much matter as can lie upon the head of her needle, 
and after that binds up the little wound with a hollow bit of 
shell ; and in this manner opens four or five veins. The Grecians 
have commonly the superstition of opening one in the middle 
of the forehead, one in each arm, and one on the breast, to make 

* The letter is addressed to Mrs. S. C. (Sarah Chiswell). 



304 TEXT-BOOK OF HYGIENE. 

the sign of the cross ; but this has a very ill effect, all these 
wounds leaving little scars, and is not done by those that are 
not superstitious, who choose to have them in the leg or that 
part of the arm that is concealed. The children or young pa- 
tients play together all the rest of the day, and are in perfect 
health until the eighth. Then the fever begins to seize them, and 
they keep their beds two days, very seldom three. Tliey have 
rarely above twenty or thirty in their faces, which never mark ; 
and in eight days' time they are as well as before their illness. 
Where they are wounded there remain running sores during 
the distemper, which I don't doubt is a great relief to it. Every 
year thousands undergo this operation ; and the French ambas- 
sador says pleasantly : ' They take the small-pox here by way of 
diversion, as they take the waters in other countries.' There is 
no example of any one that has died in it, and you may believe 
that I am well satisfied of the safety of the experiment, since I 
intend to try it on my dear little son. 

"I am patriot enough to take pains to bring this useful 
invention into fashion in England; and I should not fail to 
write to some of our doctors very particularly about it, if I knew 
any of them that I thought had virtue enough to destroy such a 
considerable branch of their revenue for the good of mankind. 
But that distemper is too beneficial to them not to expose to all 
their resentment the hardy wight that should undertake to put 
an end to it. Perhaps, if I live to return, I may, however, have 
courage to war with them." 

Soon after the date of this letter the writer's son was 
inoculated in Turkey, and four years later her daughter also, 
being the first subject inoculated in England. The practice 
soon became popular, but several fatal cases among prominent 
families brought it into disrepute, and for about twenty years 
very few inoculations were made in England. It was revived 
about the middle of the century by the founding of a small-pox 
and inoculation hospital in London. This continued in opera- 
tion until 1822. The records of this institution showed that only 



I 



SMALL-POX. 305 

three in a thousand died of the disease thus communicated. The 
practice has now fallen into desuetude, being superseded by vac- 
cination and prohibited by law in En^-land. 

Inoculation was introduced into this country in 1721 by 
Dr. Zabdiel Boylston, of Boston, who had his attention directed 
to the practice by Cotton Mather, the eminent divine.^ During 
1721 and 1722, 286 persons were inoculated by Boylston and 
others in Massachusetts, and 6 died. These fatal results ren- 
dered the practice unpopular, and at one time the inoculation 
hospital in Boston was closed by order of the Legislature. 
Toward the end of the century an inoculating hospital was again 
opened in that city. 

Early in the eighteenth century inoculation was extensively 
practiced by Dr. Adam Thomson, of Maryland, who was instru- 
mental in spreading a knowledge of the practice throughout 
the Middle States ' 

In China and India, and perhaps other eastern countries, 
inoculation was practiced at a very early period. 

The inoculation of variolous matter, although it mitigated 
to a very great degree the attack of small-pox following, had 
one very serious objection, aside from the small death-rate which 
was a direct consequence of it. This was the fact that inocula- 
tion always produced small-pox, and thus assisted in propagating 
the disease; for, however mild the induced disease might be, the 
inoculated individual was liable to communicate small-pox to 
others in the most virulent form. Hence, nothing short of uni- 
versal inoculation, which was manifestly impracticable, would 
succeed in reducing the danger from the disease. 

Vaccination. — It had been noticed at various times that a 
pustular disease which sometimes appears on the udders of cows, 
called cow-pox, had not infrequently been transmitted to the 
hands of the dairy-maids and others having much to do with 

*Dr. John R, Quinan (Md. Med. Journ., June 23 and 30, 1883) believes the claim of Dr. 
Boylston to be the first American inoculator open to question. The evidence presented is, how- 
ever, insufficient to discredit the claim of the Boston physician. 

''See Quinan, loc. cit., p. 114. 



306 TEXT-BOOK OF HYGIENE. 

COWS. In course of time it was also noticed that persons who 
had been thus attacked never suffered from small-pox. This 
protective power of cow-pox was known as early as 1713, and 
in 1774 Benjamin Jesty, a Gloucestershire farmer, performed 
vaccination for the first time on record, inoculating his wife and 
two sons with cow-pox matter as a protection against small-pox. 

It is stated that when it became known that Jesty had 
vaccinated his wife and sons, "his friends and neighbors, who 
had hitherto looked upon him with respect, on account of his 
superior intelligence and honorable character, began to regard 
him as an inhuman brute, who could dare to practice experi- 
ments upon his family, the sequel of which would be, as they 
thought, their metamorphosis into horned beasts. Consequently 
the worthy farmer was hooted at, reviled, and pelted whenever 
he attended the markets in his neighborhood."^ 

In 1791 a school-teacher in Holstein also inoculated three 
boys with the matter of cow-pox, but nothing is known of the 
subsequent history of these cases. 

Although the above facts are clearly established, it is to 
Edward Jenner, a modest country doctor of Berkeley, in the 
county of Gloucester, England, that the merit of demonstrat- 
ing the protective power of cow-pox against small-pox, and of 
difi'using a knowledge of this fact, is due. Jenner had his atten- 
tion directed to the asserted protection conferred by cow-pox 
during the period of his apprenticeship. After a residence in 
London as a pupil of John Hunter, he returned to the country 
to practice his profession. About the year 1776 he began 
studying the question, and gathering evidence of the protection 
afforded against small-pox by the accidental inoculation of cow- 
pox virus. For twenty years he studied the subject, patiently 
awaiting an opportunity to put his belief to the test of experi- 
ment. On the 14th of May, 1796, he made his first vaccination 
on a boy named James Phipps. Six weeks later he inoculated 
this boy with variolous matter, but without success, no small- 

» London Lancet, September 13, 1862. 



SMALL-POX. 307 

pox resulting. T\yo years later he published his pamphlet, 
entitled " An Inquiry into the Causes and Effects of the Variola 
Vaccinae, etc.," in which he detailed his observations and experi- 
ments. This publication produced a great sensation in the 
medical world, and, although much opposition was at first 
manifested toward his views, he soon gained many adherents. 

Vaccination, as the operation for the inoculation of cow-pox 
virus is termed, was rapidly introduced into all civilized countries, 
and soon demonstrated its good effects by greatly restricting the 
prevalence of small-pox. It is generally believed that the first 
one to practice vaccination in this country was Dr. Benjamin 
Waterhouse, of Boston, in the summer of 1 800 ; but Dr. John 
R. Quinan has recently shown ^ that vaccination was introduced 
into Maryland, by Dr. John Crawford and Dr. James Smith, at 
least as early as the date generally assigned for its introduction 
into Massachusetts. 

It was believed by Dr. Jenner, and was afterward conclu- 
sively shown by a number of distinguished experimenters, that 
vaccinia, as the disease produced by cow-pox inoculation was 
called, was merely a modification of small-pox as it existed in 
the cow. Small-pox virus, when inoculated upon the cow, 
produced cow-pox; but the latter, re-inoculated upon man, 
produced cow-pox (vaccinia), and not small-pox. Sheep-pock 
and horse-pock, or " grease," are probably merely modifications 
of the disease produced by inoculating small-pox into those 
animals. 

When cow-pox virus is successfully inoculated into the 
human system — that is, when a person is successfully vaccinated 
— the following local and general symptoms are observed : — 

In the case of a primary vaccination, i.e., where the 
individual has not been previously vaccinated or attacked by 
small-pox, the point where the vaccination is made shows no 
particular change for the first two days. If the vaccination is 
successful, a small, reddish papule appears by the third day, 

* Quinan, loc. cit., pp. 118, 131. 



308 TEXT-BOOK OF HYGIENE. 

which, by the fifth or sixth day, has become a distinct vesicle of 
a bluish-white color, with a raised edge and a peculiar, central, 
. cup-like depression called the umbilication. By the eighth day j 
this vesicle has become plump, round, and pearl-colored, the 
central umbilication being still more marked. At this time a 
red, inflamed circle, called the areola, appears, surrounding the 
vesicle and extending usually in a radius of from ^ to 2 inches 
when fully developed. This inflammatory ring is usually pretty 
firm, and there is more or less general fever and often enlarge- 
ment and tenderness of the axillary glands. After the tenth 
day the areola begins to fade, and the contents of the vesicle 
dry into a hard, brownish crust or scab, which falls off* between 
the twentieth and twenty-fourth days, leaving a punctated scar, 
which gradually becomes white. 

When the vaccinia has passed through all of these stages, 
especially if the vesicle filled with pearly lymph, and the areola 
have been well developed, the vaccination may be considered a 
success, and the individual protected against small-pox for a 
number of years, if not for life. Recently the doctrine has been 
strongly advocated that vaccination is not absolutely protective 
until a subsequent inoculation of vaccine fails to " take." 
According to this view, vaccination should be repeated until it 
fails any longer to exhibit any local reaction. When this has 
been attained the individual may be considered absolutely 
protected for life. Theoretically, this view has much in its 
favor, but there is, as yet, not sufficient evidence to establish it 
as a law. 

It may be stated as an established fact that vaccination, 
although carefully performed and successful, does not confer 
absolute immunity from small-pox for life. The protective 
power seems to wear out after a time and the individual then 
again becomes susceptible to small-pox. An attack of small- 
pox in a vaccinated individual is, however, nearly always much 
milder than where there had been no vaccination. There is no 
fact in the entire range of medicine better established than this • 



SMALL-POX. ' 309 

that small-pox in vaccinated persons is a much less dangerous 
disease than typhoid fever, while in unvaccinated cases the 
mortality ranges from 30 to 4:0 per cent. An approximate 
guide to the beneiicent influence of vaccination upon the 
mortality from small-pox is furnished by a table in Seaton's 
report on vaccination. Before the introduction of vaccination 
the mortality from small-pox, per million of inhabitants of Eng- 
land, was nearly 3000 per year. After the introduction of vac- 
cination the mortality was reduced to 310 per million per year. 

The most remarkable and convincing statistical evidence 
on the question is given by Drs. Seaton and Buchanan, of 
England. During the small-pox epidemic in London, in 1863, 
they examined over 50,000 school-children, and found among 
every thousand without evidence of vaccination 360 with scars 
of small-pox, while of every thousand presenting some evidence 
of vaccination only 1.78 had any such traces of small-pox to 
exhibit.^ The reliability of general mortality statistics may be 
called in question — in some cases, with justice; but the signifi- 
cance of these figures cannot be evaded. 

The upper and outer surface of the arm is usually chosen 
as the point where the virus is inserted, although any part of 
the body which can be protected against friction, or other 
mechanical irritation, may be selected. The method varies 
slightly in the hands of different vaccinators. The two methods 
most frequently in use are scarification and erasion. The 
former method has the indorsement of Mr. Seaton, the high 
English authority. The method of erasion — scraping off the 
epidermis until the papillary layer of the skin is laid bare — is 
now most frequently used in this country. The best instrument 
to use is a clean thumb-lancet ; in default of this, an ordinary 
sewing-needle answers well. Where animal vaccine is used, 
the ivory slip or sharpened quill may also be used with satis- 
faction to make the scarification or erasion. Whatever instru- 
ment is used, it should ahvays be kept perfectly clean. 

» Seaton, " Vaccination," in Reynolds's System of Medicine, vol. i, p. 291. Second edition. 



310 TEXT-BOOK OF HYGIENE. 

A point of vital importance is that which relates to the 
proper age at which children should be vaccinated. Ordinarily, 
vaccination should be performed within the first six months of 
life. In time of danger from a threatened, or in the presence 
of an actual, epidemic, infants may be vaccinated when only 1 
day old. 

In order to secure permanent protection against small-pox, 
revaccination should be performed after a certain interval. 
Some place the period at which this second vaccination should 
be done at five years, while others allow a longer interval — 
seven, eight, or ten years. The law of Prussia is that every 
child that has not already had small-pox must be vaccinated 
within the first year of its life, and every pupil in a public or 
private institution is to be re vaccinated during the year in 
which his or her twelfth birthday occurs. 

This law was passed in 1874. Prior to this time the 
mortality from small-pox was 15 to 20 per 100,000 of the 
population. Since the law was enacted the small-pox mortality 
has varied from 0.3 to 3.6 per 100,000. Not a single death 
from small-pox occurred in the German army between 1874 
and 1882.' 

A revaccination, even if successful, seldom passes through 
all the typical stages of a primary vaccination. The vesicle 
rarely becomes so full and plump, and is more frequently flat 
and irregular in outline. Swelling of the axillary glands and 
other complications also seem to be more frequent than in cases 
where the vaccination is done for the first time. 

The question whether the lymph direct from the cow or 
humanized lymph is the more efiicient has caused much dis- 
cussion. The objections urged against the use of humanized 
virus are : first, that its protective power has become diminished 
by transmission through many generations ; second, tliat it is 
liable to transmit other diseases, such as syphilis, tuberculosis, 
scrofula, etc.; third, that it is frequently difiicult to obtain in 

» Frolich, Militar-Medicin, p. 461. 



SMALL-POX. 311 

sufficient quantities in an emergency, such as an actual or 
threatened epidemic. 

The first objection is disproved by the testimony of many 
of the most distinguished medical men in Europe and this 
country. Humanized vaccine virus, when properly inoculated, 
seems to be as completely protective against small-pox as that 
taken direct from the animal. Among its advantages are, that 
it " takes " more readily and runs through its stages of develop- 
ment in a shorter time, and that it will retain its active proper- 
ties for a greater length of time than animal virus. The 
physician can usually control the source whence he obtains it. 
He can watch over the subject that furnishes it and reject that 
which is suspicious. With humanized lymph collected by the 
physician himself there can be no doubt as to its purity or age ; 
with animal lymph furnished by the cultivators of that article 
there can be no certainty about either of these important points. 

That syphilis has been inoculated with humanized virus 
can no longer be open to doubt. The recent experiment of 
Dr. Cory, of England, has settled this question definitely. With 
care, however, this sad accident can easily be avoided, and the 
fact that syphilis has been so rarely transmitted by vaccination 
is sufficient evidence that the danger of such infection is not 
very great. 

The most serious objection against the exclusive use of 
humanized lymph is, that in grave emergencies, such as a 
rapidly-spreading epidemic of small-pox, it is difficult to obtain 
a sufficient supply of the lymph. 

Humanized virus is inoculated, either in the fresh state, 
i.e., the lymph is taken from the vesicle on the seventh day and 
inoculated directly into the arms of other individuals, or else the 
vesicle is allowed to dry into a crust, with which a thin paste is 
made by moistening with water at the time of vaccination. The 
readiest way of using the crust is to crush a small fragment 
between two small squares of glass, then moistening it with a 
drop of warm (not hot) water, and smearing it on the spot 



312 TEXT-BOOK OF HYGIENE. 

where the vaccmation is to be made. With the lancet a 
number of cross-scarifications are then made, and the virus well 
rubbed in. Only so much of the crust should be moistened as 
will be used at the time. Particular care must be taken not to 
use saliva for moistening the crust. Aside from being unclean, 
there is danger of producing blood-poisoning by inoculating 
certain of the oral secretions.^ 

Animal virus is obtained by inoculating a calf or heifer 
with virus, either derived from a case of small-pox, from another 
case of cow-pox, or by re-inoculating humanized vaccine virus 
into the animal. The vesicles are opened on the seventh day, 
and ivory points or the ends of quills coated with the lymph 
and dried with a gentle heat. 

In vaccinating with animal virus, the quill or ivory point 
is first moistened with a drop of water to soften the adhering 
lymph ; the scarification or abrasion of the skin is then made 
with the lancet, and the virus rubbed well into the scarified 
spot. 

In using animal virus the successive stages of development 
are usually one or two days later than when humanized virus 
is used. In the former case the areola is rarely developed 
before the ninth day. 

Certain complications are likely to occur in the course of 
the vaccinia, of which the student should be aware. 

When the areola appears there is usually more or less 
fever. Sometimes the constitutional manifestations are de- 
cidedly marked, fever of a high grade being not uncommon. 
In addition to the glandular enlargement and tenderness, an 
outbreak of roseola sometimes comes on about the ninth or 
tenth day. This eruption may be mistaken for scarlet fever, 
but if it is remembered that two infectious diseases rarely co- 
exist in one individual during their full development this error 
will be avoided. 

Erysipelas involving the entire arm is sometimes observed 

* See Sternberg and Magnin, Bacteria, p. 355. Second edition. 



SMALL-POX. 313 

as a complication of vaccination. This, in nearly every case, 
depends upon some depravement of the patient's constitution, 
innutrition, bad sanitary surroundings, or, perhaps, more fre- 
quently, chronic alcoholism. Individuals who are habitually 
intemperate in the indulgence of alcohohc liquors are espe- 
cially unfavorable subjects for vaccination. The results are, 
fortunately, rarely serious to the patient. 

Another inconvenient complication of vaccination is the 
formation of a deep, ill-looking, sloughing ulcer at the vacci- 
nated point. This has been, in the author's experience, a much 
more frequent concomitant when animal virus has been used than 
when humanized virus was resorted to. It should be borne in 
mind that a very sore arm, especially if followed by the formation 
of an ulcer or gangrenous so.re, may not be protective against 
small-pox. Such a patient should not be considered properly 
vaccinated, and must be revaccinated as soon as he recovers, or 
immediately if there is any danger of small-pox mfection. 

Children with eczematous eruptions, however, localized 
upon any portion of the body, should not be vaccinated until 
the eruption is first cured, except in times of danger from 
small-pox. The eczema will be almost certainly rendered worse 
in consequence of the general hyperaemia accompanying the 
febrile reaction, and the physician who performs the vaccination 
will be blamed for causing the skin disease. 

The author has placed on record^ two cases of general 
psoriasis following vaccination, and other cases haA^e been since 
reported. Urticaria and exudative erythema have also been 
repeatedly observed. 

As before stated, syphilis may be communicated to the 
vaccinee by vaccine virus obtained from a syphilitic subject, but 
this accident is infrequent. There can be little doubt that some 
of the cases reported as " vaccinal syphilis " are cases of tardy 
hereditary syphilis, lighted up by tlie general systemic disturb- 
ance following vaccination. 

* Journal Cutaneous and Venous Diseases, vol, i, No. 1, p. 11. 



314 TEXT-BOOK OF HYGIENE. 

Next in importance to vaccination in the prophylaxis of 
small-pox is prompt isolation of the sick. No one but the 
medical and other attendants of the sick should be allowed to 
come in contact with them. All attendants and other persons 
exposed to the infection should, of course, be promptly vacci- 
nated, unless this has been successfully done within the previous 
year or two. 

Disinfection of all discharges from the patient and of the 
room and its contents, after the patient has recovered or died, 
must be practiced. The best disinfectants in small-pox are 
bichloride of mercury, free chlorine, and sulphurous acid. 

When it is learned that a person has small-pox, if he is not 
removed to a special hospital, a room should be prepared for his 
occupancy. The carpets should be taken up and the floor kept 
clean. Window-curtains and unnecessary furniture and drapery 
should be removed from the room. After recovery of the 
patient the bed-clothing must be thoroughly disinfected with 
steam or sulphurous acid, or destroyed by fire. The individual 
himself should not be allowed to mingle with healthy persons 
until all danger of infection is passed and the surface of his 
body has been thoroughly disinfected. 

ASIATIC CHOLERA. 

A disease which causes the death of three-fourths of a 
million of human beings in the country where it is endemic, 
within the space of five years, and which makes periodical ex- 
cursions, spreading over nearly the entire inhabited globe with 
destructive violence, must surely command the interested atten- 
tion of every intelligent person. 

Asiatic cholera is an endemic disease of India, where it 
probably originated centuries ago. Some authors claim to have 
found satisfactory evidence of its existence in the writings of the 
classical authors of India and Greece at a period as early as the 
second century of the Christian era. The evidence is, however, 
not beyond question. In the sixteenth and seventeenth cen- 



ASIATIC CHOLERA. 315 

turies European travelers in the East gave pretty exact accounts 
of the disease. One of the most definite of these was given by 
Gaspar Correa, an officer in Vasco da Gama's expedition to 
Cahcut. He states that Zamorin, the chief of Calicut, lost 
20,000 of his troops by the disease. A still more definite and 
the first trustworthy account is that of Sonnerat, a French trav- 
eler. He describes a pestilence havhig all the characters now 
recognized as belonging to Asiatic cholera, w^hich prevailed in 
the neighborhood of Pondicherry and the Coromandel coast in 
1768 and 1769, and which carried off 60,000 of those attacked 
by it within a year. Dr. Macpherson, in his " History of Cholera," 
gives numerous references which indisputably establish the en- 
demic existence of the disease in India anterior to the present 
century. 

Being endemically prevalent over a greater or less area of 
India for many years, cholera finally, in 1817, crossed the 
boundaries of that country, and, advancing in a southeasterly 
direction, invaded Ceylon and the Sunda Islands in 1818. In a 
westerly direction the disease was carried to the islands of 
Mauritius and Heunion, and reached the African coast in 1820. 
During this year it also traveled northeasterly, devastating the 
Chinese Empire for the two following years, reaching Nagasaki, 
in Japan, in 1822. 

In 1821 the disease spread from India in a westerly direc- 
tion, extending along the east coast of Arabia to the border of 
Mesopotamia and Persia. In the spring of 1822 it began with 
renewed violence, following tlie river Tigris to Kurdistan, and, 
extending farther in a westerly direction, reached the Mediter- 
ranean coast of Syria. In the following year, 1823, it extended 
from Persia into Asiatic Hussia, reaching Astrachan on the 
European border in September, but dying out nearly every- 
where beyond the borders of India during the ensuing winter. 

In 1826 cholera again advanced from India, reaching 
Orenburg in Pussia in 1829, and in the following winter 
appeared in St. Petersburg. Extending to the north and south, 



316 TEXT-BOOK OF HYGIENE. 

it invaded Finland and Poland the same year. From Persia 1 
disease spread to Egypt and Palestine in 1830-31. 

From Russia the pestilence invaded Germany in 1831, 
passing thence in 1832 into France, the British Isles, Belgium, 
the Netherlands, Norway, and Sweden. In the latter year 
cholera crossed the Atlantic Ocean for the first time, being car- 
ried to Canada by emigrants from Ireland, and spreading thence 
to the United States by way of Detroit. In the same year it 
was imported into New York by emigrants, and rapidly spread 
along the Atlantic coast. During the winter of 1832 it appeared 
at New Orleans, and passed thence up the Mississippi Valley. 
Extending into the Indian country, causing sad havoc among 
the aborigines, it advanced westward until its further progress 
was stayed by the shores of the Pacific Ocean. In 1831: it 
re-appeared on the east coast of the United States, but did not 
gain much headway, and in the following year New Orleans was 
again invaded by way of Cuba. It was imported into Mexico in 
1833. In 1835 it appeared for the first time in South America, 
being restricted, however, to a mild epidemic on the Guiana coast. 

While the pestilence was advancing in the Western Hemi- 
sphere, it also spread throughout Southern Europe, invading, in 
turn, Portugal, Spain, and Italy. 

Extendmg in an easterly direction from India, the disease 
reached China and Japan in 1830-31 ; westwardly, Africa 
was invaded in 1834, and ravaged by the epidemic during the 
following three years. 

This second extensive outbreak of cholera ended in 1837, 
disappearing at all points beyond the borders of India. In 
1846 the disease again advanced beyond its natural confines, 
reaching Europe, by way of Turkey, in 1848. In the autumn 
of this year it also appeared in Great Britain, Belgium, the 
Netherlands, Sweden, and the United States, entering by way of 
New York and New Orleans. In the succeeding two years the 
entire extent of country east of the Bocky Mountains was in- 
vaded. During 1851 and 1852 the disease was frequently im- 



ASIATIC CHOLERA. 317 

ported by emigrants, who were annually arriving in great num- 
bers from the various infected countries of Europe. In 1853 
and 185 J:, cholera again prevailed extensively in this country, 
being, however, traceable to renewed importation of infected 
material from abroad. In the following two years it also broke 
out in numerous South American States, where it prevailed at 
intervals until 1863. 

Hardly had this third great pandemic come to an end 
before the disease again advanced from the Ganges, spreading 
throughout India, and extending to China, Japan, and the East 
India Archipelago during the years 1863 to 1865. In the latter 
year it reached Europe by way of Malta and Marseilles. It 
rapidly spread over the Continent, and in 1866 was imported into 
this country by w^ay of Halifax, New York, and New Orleans. 
This epidemic prevailed extensively in the Western States, but 
produced only slight ravages on the Atlantic coast, being kept 
in check by appropriate sanitary measures. In the same year 
(1866) the disease was also carried to South America, and in- 
vaded, for the first time, the States bordering on the Rio de la 
Plata and the Pacific coast of the Continent. 

While the epidemic w^as thus advancing westward from its 
home in India, it was at the same time spreading northwardly 
over the entire western part of Asia, and in a southeasterly 
direction over Northern Africa. In the latter continent it pre- 
vailed from 1865 to 1869. 

Cholera never entirely disappeared in Russia during the 
latter half of the sixth decade, and in 1870 it again broke out 
with violence, carrying ofi" a quarter of a million of the inhabi- 
tants before dying out in 1873. It spread from Russia into 
Germany and France, and was imported, in 1873, into this 
country, entering by w^ay of New Orleans and extending up 
the Mississippi Valley. None of the Atlantic-coast cities suf- 
fered from the epidemic in 1873, and since that year the United 
States have been entirely free from the disease, with the excep- 
tion of a few imported cases in New York Harbor in 1887. 



318 TEXT-BOOK OF HYGIENE. 

In June, 1883, a new epidemic of cholera broke out in 
Egypt, where it raged with great violence. The disease first 
appeared in Damietta, near the outlet of the Suez Canal. It 
was unquestionably imported from India, probably Bombay, 
where it prevailed as early as the month of May. At the time 
of the outbreak in Damietta that city was overcrowded with 
people who had come to attend a great religious fair and festival. 
It has been proven that pilgrims from Bombay were among the 
attendants at this fair. The epidemic came to an end in Egypt 
in the autumn of 1883. In the same year (1883) a small out- 
break occurred in Marseilles, but intelligence of it was carefully 
suppressed by the authorities. The disease does not seem to 
have spread from this centre, but in June of the following year 
cholera broke out in Toulon, having probably been imported in 
a transport ship returning from Tonquin. This outbreak was 
very violent and rapidly spread throughout Southern France, 
Italy, and Spain. After apparently dying out during the winter, 
it re-appeared in the spring of 1885 with renewed violence. The 
total number of cases in Spain alone in the latter year was over 
one-third of a million, with nearly 120,000 deaths. 

In the summer of 1885 cholera also broke out in a viru- 
lent form in Japan, and, after a cessation during the following 
winter, recurred with increased fatality in 1886. In the latter 
year there were over 100,000 deaths from the disease in that 
country. 

During 1886 and 1887 cholera continued in Southeastern 
Italy and in the Austrian dominions at the head of the Adriatic. 
A few cases occurred in France and Germany, but by stringent 
sanitary measures an epidemic was averted. 

In November, 1886, cholera was carried to South America 
in an Italian ship, the "Perseo," bound from Genoa to Buenos 
Ayres. The disease rapidly spread in the Argentine Republic, 
and, crossing the Andean range, invaded the Pacific coast of the 
South American continent for the second time, reaching Chili 
and Bolivia and threatening Peru and Brazil. In Chili alone 



ASIATIC CHOLERA. 319 

there were over 10,000 deaths in the first six months of 1887. 
The further progress of the epidemic was arrested and the entire 
Western Hemisphere is now free from the disease. 

From July to December, 1889, cholera prevailed with con- 
siderable virulence in Mesopotamia. This epidemic seems, at 
the time of writing (February 1, 1890), to be at an end. 

This brief historical sketch of all the epidemics of cholera 
observed beyond the borders of India demonstrates several 
facts: first, that the home or breeding-place of cholera is in 
India, especially the delta of the Ganges, whence it spreads at 
intervals throughout the world; second, that it always advances 
along the lines of travel of large bodies of human beings ; and, 
third, that it advances, by preference, along water-routes. The 
latter is particularly noticeable in the behavior of cholera epi- 
demics in this country. When it has spread from an Atlantic 
port, it has, generally, been to other places having water com- 
munication with that port. Exceptions undoubtedly occur, but 
the rule is a general one. The disease seems to spread with 
difiiculty along the lines of railroad. When the disease has 
extended from New Orleans it has always been up the Mississippi 
Valley, expending its violence upon the river cities — Vicksburg, 
Memphis, St. Louis, and Cincinnati. 

Several factors must concur before there can be an epidemic 
of cholera. These are : first, the cholera poison ; second, cer- 
tain local conditions of air, soil, or water ; and, third, individual 
predisposition. Without a concurrence of all these conditions 
no outbreak can occur. If, by any means, the co-existence of 
these three conditions can be prevented, cholera can be averted. 
The following are facts bearing upon this question : Cholera is 
communicated through the agency of a specific poison. This 
does not admit of doubt. The poison may be either an organic 
germ, or of an inorganic, particulate, or gaseous nature. The 
recent researches of Dr. Robert Koch, of Germany, indicate 
that a micro-organism found in the intestinal discharges of cholera 
patients and in the bodies of those dead with the disease is the 



320 TEXT-BOOK OF HYGIENE. 

active agent in propagating the malady. This organism, named 
by Koch the "comma bacillus," from its general resemblance 
to a comma, was first discovered by this eminent pathologist in 
the intestinal contents of cholera corpses in Egypt in 1883, and 
in the following year more thoroughly studied in Calcutta, 
whither he had been sent by the German government to pursue 
his investigations. It has been demonstrated that this germ is 
always present in the discharges of cholera patients, and up to 
this time it has not been found in any other disease. Experi- 
ments upon animals have also shown that cholera can be pro- 
duced in the latter by introducing the germ into their bodies in 
various ways. The demonstration of the bacterial nature of 
cholera seems to be complete. 

While cholera cannot be regarded as personally contagious 
in the same sense or in the same degree as small-pox, there can 
be no doubt that it is spread only by the poison from other cases 
of the disease. The regularity of its march along routes by 
which the intercourse of human beings takes place, and always 
in connection with other cases of cholera, proves this. There is 
no undoubted case on record where genuine cholera has been 
spontaneously developed outside of India. 

That certain local geological and perhaps meteorological 
conditions are necessary for the propagation or virulence of the 
poison of cholera is beyond dispute. Outbreaks usually take 
place during the summer or autumn, and nearly always partly 
or entirely die out during cold weather. Further, in nearly all 
epidemics, certain cities or towns, or portions of a town, into 
which persons sick with cholera are brought, and where the 
poison of the disease is thus imported, remain exempt from the 
effects of the epidemic. Tlie inference to be drawn from this 
fact is that in such localities the local conditions are unfavorable 
to the development of the poisonous germ, and it becomes inert. 

In India all the local conditions favorable to the propagation 
of the cholera-germ are found. The filthy personal habits of 
the people, the overcrowding, the intense heat, the lack of suf- 



ASIATIC CHOLERA. 321 

ficient, appropriate, or properly-prepared food, and the exten- 
sive pollution of the water-supply, all combine to produce the 
necessary conditions of development of the cause of cholera. 
These conditions, doubtless, to a considerable extent, give rise 
to that depression of the system which seems necessary to con- 
stitute the individual predisposition to become infected. 

Given, then, at any place, a number of persons of a lowered 
degree of vitality, — that is to say, persons not capable of resisting 
unfavorable influences upon their health under unfavoring con- 
ditions ; given conditions of climate, water, and soil more or less 
similar to those existing in India : only the introduction of the 
third factor, the cholera poison, is needed to cause an outbreak. 
In many cities of this country and Europe, as proven by the 
most recent epidemics in Toulon, Marseilles, Naples, and other 
cities of Italy and Spain, the conditions are present which would 
furnish the most favorable breeding-place for the cholera-germ 
if introduced. 

The dejections and vomited matters of cholera patients con- 
tain the active agent which produces the disease. The contagi- 
ous principle contained in these excretions, probably the cholera- 
germ or " comma bacillus " discovered by Koch, may gain an 
entrance into the body through the drinking-water or through 
infected air. Probably both modes are equally competent chan- 
nels of infection. The prevailing theory is that pollution of the 
drinking-water is the most frequent source of the rapid spread 
of the disease. A very striking instance of this occurred in 
London during the epidemic of 1854, which has already been 
referred to.^ 

iVnother striking instance of the communication of cholera 
by polluted water has been reported by Mr. John Simon, long the 
chief medical officer of the English "Local Government Board." 
The facts are as follow : The Lambeth Water Company drew 
its supply from the Thames, at Ditton, above the influence of 
the London sewage and the tidal flux. The Southwark and 

* See ante, page 64. 
21 



322 TEXT-BOOK OF HYGIENE. 

Vauxhall Company drew its supply from the river near Vauxhall 
and Chelsea. The water of the Lambeth Company was toler- 
ably pure, and that of the South wark and Vauxhall Company 
was very impure. The water of both companies was distributed 
in the same district at the same time and among the same class 
of people, the pipes of the two companies being laid pretty 
evenly in the same areas, in many places running side by side 
in the same streets, and the houses supplied being pretty equally 
distributed. The deaths from cholera in the houses supplied by 
the Lambeth Company were at the rate of 37, and in the houses 
supplied by the South wark and Vauxhall Company at the rate 
of 130, to every 10,000 persons living. It appears, therefore, 
that of the drinkers of the foul water about three and a half 
times as many as those who drank the pure water died of cholera. 

But the spread of cholera cannot always be referred to pol- 
lution of the drinking-water. In many epidemics no relation 
can be shown to exist between the spread of the disease and im- 
pure water. Professor von Pettenkofer, of Munich, has shown, 
by a number of carefully-conducted observations, that the prop- 
agation of cholera often bears a very direct relation to changes 
in the stage of the subsoil- or ground- water. This does not 
mean that the subsoil-water is directly or necessarily the agent 
for the spread of the disease, but that its stage, or variabihty, — 
now high, now low, — may be considered as an index of certain 
processes going on in the soil which are intimately connected 
with the propagation of cholera as well as of certain other in- 
fectious diseases, chief among which is typhoid fever. The 
relations between the ground-water level and cholera outbreaks 
in India and various cities in Europe and America give strong 
support to the views of von Pettenkofer.^ 

In addition to the influence of the ground-water oscillations 
and polluted drinking-water in spreading the cholera-poison, 
must be mentioned articles of food contaminated with the in- 
fectious matter of the disease. It is also no longer open to 

» See page 130. 



ASIATIC CHOLERA. 323 

question that persons may become infected by handling the 
clothing and bedding of cholera patients. Laundresses are in 
special danger from this source. Physicians and nurses have, 
not rarely, been attacked under circumstances which pointed 
strongly to personal contagion as one of the sources of the disease. 

The prophylaxis against cholera comprises such measures 
as will prevent the admission of the cholera-poison into a com- 
munity, arrest the development of the poison after its introduc- 
tion, and reduce the individual susceptibility to attack. 

It is evident from the foregoing that if the introduction of 
the cholera-poison could be prevented no outbreak of the dis- 
ease could occur. With this in view, some have urged the en- 
forcement of a strict policy of non-intercourse with infected 
localities. But at the present day few sanitarians advocate these 
extreme measures. A modified system of restricted intercourse 
is supported by many authorities, who claim that by the adoption 
of a thorough system of maritime inspection, disinfection, and 
observation — a rational quarantine, in fact — the poison can be 
rendered ineffective or its entrace into a commmunity prevented. 

The best authorities, however, think that it is not only 
easier, but far more efiective to place the threatened locality in 
such a sanitary condition that the development of the cholera- 
poison cannot take place. The contrast between the effective- 
ness of quarantine and local sanitation as safeguards against 
cholera has been well expressed by von Pettenkofer, who com- 
pares cholera epidemics to powder explosions. The virus of 
cholera, he says, is the spark that evades the strictest quaran- 
tine ; the powder is the ensemble of local conditions which pre- 
dispose to the outbreak. " It is wiser, therefore, to seek out and 
remove the powder than to run after and try to extinguish each 
individual spark before it drops upon a mass of powder, and, 
igniting it, causes an explosion which blows us into the air with 
our extinguishers in our hands." 

The measures of local sanitation to be enforced are such 
as will secure cleanliness of person, of habitation and surround- 



324 TEXT-BOOK OF HYGIENE. 

iiigs, of air, of water, and of soil. Pollution of the soil should 
be especially guarded against, for a polluted soil means impure 
air and water, and these mean, if not an infectious disease, 
at least a heightened receptivity to its influence. The quality 
of the drinking-water used must be above suspicion of con- 
tamination by the poison. Unless the latter can be positively 
excluded all drinking-water should first be boiled. It may then 
be cooled by pure ice. Filtering the water may not remove the 
poison. 

The individual predisposition to cholera is best guarded 
against by keeping the body clean and well nourished, and the 
mind free from worry. Underfeeding, anxiety, overwork, ex- 
posure to extremes of temperature, intemperance in eating and 
drinking should all be avoided, as they tend to reduce the re- 
sistance of the system to the influence of the morbid poison. 

Certain measures of personal prophylaxis which have 
proven useful heretofore should be adopted wherever cholera 
prevails. One of the best of these is the use of sulphuric-acid 
lemonade as a drink. Ten to 15 drops of dilute sulphuric acid 
in a glass of water, sweetened with sugar, may be drunk instead 
of water. Experience with it during the epidemic of 1866 has 
demonstrated its great value as a preventive of cholera. The 
later researches of Koch have also shown that the "comma 
bacillus," or spirillum, cannot live in acid solutions. Hence, 
it is probable that if the contents of the stomach Avere always 
kept acid no infection could occur through absorption from the 
stomach. 

A painless diarrhoea, called cholerine, attacks many persons 
during cholera epidemics. This disorder is easily curable if 
promptly attended to, but if allowed to run on it may develop 
into a malignant attack of cholera. 

Among the means of securing prompt treatment of the 
poorer classes in times of epidemics is the establishment of 
numerous public dispensaries, where medical aid can always be 
obtained. The establishment of such dispensaries and, if 



ASIATIC CHOLERA. 325 

possible, of temporary hospitals in the crowded portions of 
cities is a very important part of the prophylactic treatment. 

Inasmuch as it seems definitely established that the dis- 
charges from the stomach and intestines are the active agents in 
propagating the disease, the immediate disinfection of such dis- 
charges is vitally important. The stools and vomited matters 
must be rendered innocuous by germicidal agents, such as mer- 
curic chloride, carbolic acid, or chloride of lime. 

Clothing and bedding should be disinfected with super- 
heated steam, thorough boiling, or fumigation with sulphur 
dioxide or chlorine. Infected articles of this kind should not 
be sent to a laundry until they have been thoroughly disinfected 
by one of tlie above-mentioned means. 

Apartments which have been occupied by cholera patients 
should be thoroughly fumigated, before being re-occupied, with 
burning sulphur, and afterward freely exposed to the air by 
opening doors and window^s. The w^alls may also be w^ashed 
with a solution of mercuric chloride. 

The most efficient disinfectant is mercuric chloride in the 
proportion of 1 part in 2000 of the material to be disinfected. 
The readiest w^ay of securing disinfection with this agent is to 
add a solution of 1 to 1000 to an equal proportion of the dis- 
charges to be rendered innocuous. The mercuric chloride acts 
slowly, and hence the infected material should be exposed to the 
action of the disinfecting agent for at least two hours before it 
can safely be thrown into sewers or cess-pools. 

There are several serious objections to the indiscriminate use 
of mercuric chloride by the public as a disinfectant. In the 
first place, it is intensely poisonous, and its perfectly transparent 
and inodorous solution might readily be accidentally drunk and 
cause fatal results. To reduce this danger, the Committee on 
Disinfectants of the American Public Health Association recom- 
mended the addition of permanganate of potash or of sulphate 
of copper (blue vitriol) to color the solution. Another serious 
objection to mercuric chloride is that it cannot be used where 



326 TEXT-BOOK OF HYGIENE. 

the disinfected material must pass through lead pipe, as this is 
rapidly corroded by the sublimate. In many water-closets it can 
therefore not be used. 

Chloride of lime (bleaching-powder) has been found to be 
a very rapid and efficient disinfectant, as well as a deodorizer ; 
but the chlorine, upon which its effectiveness depends, is often 
so deficient in proportion, and the compound so readily deterio- 
rates that, unless a preparation can be obtained that contains at 
least 25 per cent, of available chlorine, it may prove injurious 
by causing a false sense of security. A trustworthy preparation 
may be dissolved in water, when required, in the proportion of 
1 to 100. An objection to its use is the pungent odor of chlorine, 
which is very offensive to many persons. 

Dr. Koch recommends €arbolic acid, which he has shown 
will kill the " comma bacilli " in a dilution of 1 to 20 of water. 
The ordinary preparations of carbolic acid sold as disinfectants 
are, however, not to be relied on, many of them not containing 
more than 2 per cent, of the acid. Further dilution of these 
agents would altogether destroy their disinfecting power. The 
purer article is, on the other hand, too expensive to be used as 
a disinfectant. 

Little's soluble phenyle is an efficient disinfectant in the 
proportion of 2 per cent. (1 to 50). It is furnished of uniform 
strength, is moderately cheap, non-poisonous, and readily 
miscible with water. In addition to its disinfecting power, it is 
also an excellent deodorizer, promptly removing all odors of 
decomposition and putrefaction. Its only objection is a rather 
pungent though not unpleasant odor, which somewhat resembles 
creasote. 

In the very beginning of an epidemic, prompt isolation of 
the sick and thorough disinfection of the surroundings of the 
patient may check the spread of the disease. Much cannot be 
expected from these measures, however, unless the local sanitary 
conditions are such as offer a hindrance to the development of the 
cholera-poison. It is plain, therefore, that prophylactic measures 



RELAPSING FEVER. 327 

against cholera, to be effective, must be brought into requisition 
before the epidemic has begun. After the outbreak of the 
disease it may be too late to put the threatened locality in a 
good sanitary condition. It is of the highest importance that 
preventive measures be enforced early. 

RELAPSING FEVER. 

Relapsing fever was first clearly described by Dr. John 
Rutty, in his " Chronological History of the Weather, Seasons, 
and Diseases of Dublin from. 1725 to 1765." ^ Near the end of the 
last and in the first half of the present centuries relapsing fever 
was frequently met with in an epidemic form in Ireland and 
Scotland. In 1847 the disease invaded a number of the larger 
cities of England. From 1868 to 1873 it prevailed extensively 
in England and Scotland. On the continent of Europe it was 
first observed in Russia in 1833. In Germany it was not 
recognized as a distinct disease until 1847, but did not prevail 
epidemically until 1868. Since then it has often been observed 
in that country. 

Relapsing fever is very prevalent in India, w^here it was 
first observed in 1856 by Sutherland. In China and in the 
countries of Africa bordering on the Red Sea the disease has 
been recognized by observers. 

In the United States it was first observed among emigrants 
in Philadelphia in 1844, and again in 1869. It w^as conveyed 
to other places, but has never prevailed extensively in this 
country. It has not been observed in the United States since 
1871. 

The predisposing causes of relapsing fever are, above all, 
bad sanitary surroundings. Want and overcrowding seem to be 
much less important factors than in typhus fever. 

Although relapsing fever has, since it was first clearly dis- 
tinguished from typhus and other continued fevers, been recog- 
nized as an eminently contagious and infectious disease, it was 

» London, 1770. 



328 TEXT-BOOK OF HYGIENE. 



4 



not until 1873 that its immediate cause became known. In that 
year Obermeier discovered in the blood of patients ill with this ' 
disease a minute, spiral, mobile organism, now known as the 
spirillum or spirocJicete Ohermeleri. 

Obermeier and other observers, prominent among whom is 
Dr. Henry V. Carter, have demonstrated the constant presence 
of these organisms in the blood during the attack. Carter and 
Koch have induced the disease in monkeys by inoculation of the 
parasite, and Moschutkowski has successfully inoculated it in the 
human subject. No doubt can exist at the present day that the 
spirillum of Obermeier is the true cause of relapsing fever. 

The preventive measures consist in attention to details of 
personal hygiene ; in other words, local sanitation, disinfection 
of infected materials (fomites), and complete isolation of the sick. 

TYPHOID FEVER. 

The first accurate clinical accounts of typhoid fever date 
from the seventeenth century, when Bagiivi, Willis, Sydenham, 
and others described cases of fever which in their clinical char- 
acters correspond to the disease now known as typhoid fever. 
Strother, however, in 1729, first gave a description of the 
anatomical characters of the disease, which he says is a " symp- 
tomatical fever, arising from an inflammation, or an ulcer, fixed 
on some of the bowels." Bretonneau and Louis, in France; 
Hildenbrand, in Germany ; William Jenner, in England ; and 
Drs. Gerhard and Pennock, in this country, clearly pointed out 
the essential distinction between typhoid and other fevers, during 
the first half of the present century. 

At the present day typhoid fever is met with everywhere 
throughout the world. It is at nearly all times a constituent of 
mortality tables. It affects by preference persons betAveen 
the ages of 15 and 30 years, although no age is entirely 
exempt. It is always more prevalent in the autumn and winter. 

The disease is probably due to an organic poison, which 
gains entrance into the body through the respiratory or digestive 



TYPHOID FEVER. 329 

tract. Recent observations of Klebs and Eberth seem to indicate 
that the morbific agent is a micro-organism termed the haciUits 
typlioideus. The exact relation of this organism to the disease 
has not been clearly worked out. It is found in the intestinal 
canal, and especially in the characteristic intestinal lesions of 
this fever. The infective agent is probably contained in the 
dejections of patients. The disease is not immediately conta- 
gious, like typhus fever. 

The medium through which the poison is introduced into 
the body may be drinking-water, food, milk, or other articles 
containing the infective agent. Localized epidemics due to 
mfected water or milk have been frequently reported.^ 

The typhoid poison is supposed to be developed in cess- 
pools, sewers, and soil polluted by the products of animal decom- 
position. Whether it ever originates de novo in such places is 
a much-disputed proposition. At present the evidence is in 
favor of the view that cases of typhoid fever are always derived 
from pre-existing cases. The germ may develop in sewers and 
be carried in the sewer-air from place to place ; it may be carried 
into the soil from cess-pools receiving typhoid dejections, and 
there, undergoing development, may ascend through houses 
with the ground-air, or may drain into wells and pollute the 
drinking-water. By the admixture of such water with milk or 
other food the disease may be propagated. It is also believed 
that the effluvia from typhoid discharges may be absorbed by 
water or milk, and thus infect these articles. 

The prophylactic measures against typhoid fever comprise 
isolation of the sick, prompt disinfection of the discharges, and 
cleanliness in the widest sense. The water- and food- supplies 
must be carefully guarded against contamination with the poison, 
and all decomposing animal matter and excreta must be removed 
from the immediate vicinity of dwellings. The requisites for 
prevention may be summed up as pure air, pure water, uncon- 
taminated food, and a clean soil. 

* See ante, pp. 61-64, 



330 TEXT-BOOK OF HYGIENE. 

TYPHUS FEVER. 

Wide-spread pestilences are nearly always accompaniments 
of famine and war. Of all pestilential diseases, none is so regu- 
lar in its coincidence with these conditions as typhus fever. The 
earliest accounts which unquestionably refer to this disease date 
from the eleventh century, when it was observed at a number of 
places in Italy. In the succeeding centuries isolated accounts 
of it appeared in the chronicles of the times, but no scientific 
description of it appeared until the sixteenth century. During 
the seventeenth, eighteenth, and the early part of the nineteenth 
centuries it prevailed extensively throughout Europe. The 
constant wars and consequent disturbances of the social rela- 
tions of the people, famines, overcrowding, filth, excesses of all 
kinds, contributed largely to the development and spread of 
typhus fever. For a number of years past no extensive epi- 
demic of the disease has been observed, although both in this 
country and in Europe localized outbreaks are frequently met 
with. 

Typhus fever is somewhat more prevalent in the winter and 
early spring months than during the rest of the year, but not 
very markedly so. 

At present, typhus fever is nearly always limited to times 
and places where the conditions favoring its development exist. 
Wherever overcrowding, in connection with filth, insufiicient 
food, and bad habits are present, typhus fever is likely to be a 
visitor. Thus, in overcrowded and ill-ventilated emigrant ships, 
in jails and work-houses, and in camps, especially when stress 
of weather compels the crowding together of soldiers in close 
huts or barracks, the disease frequently breaks out. 

When typhus fever appears in a community, those classes 
of the people who are subjected to the conditions just mentioned 
are almost exclusively attacked. In cities, the dwellers in 
crowded tenements, or in courts and alleys, sufier most severely — 
are, in fact, almost the only ones attacked. An exception must, 
however, be made in the case of hospital physicians and attend- 



YELLOW FEVER. 331 

ants where typhus-fever patients are treated. The mortahty 
among these is always large. 

Typhus fever is contagious and infectious. An exposure 
for a length of time to an atmosphere impregnated with the 
poison may suffice to induce an attack. The poison may also 
be conveyed from place to place in fomites. Physicians may 
carry it in their clothing, if they have been exposed to a typhus 
atmosphere. 

The prevention of typhus fever consists in the institution of 
such measures as will secure pure air, pure water, a clean soil 
and dwellings, and cleanliness of body and clothing. When an 
outbreak occurs, the sick should be promptly isolated, the well 
persons removed from the building in which the cases have 
occurred, and efficient measures of disinfection carried out. The 
sick should be treated in the open air as much as possible. 

YELLOW FEYER. 

The West India Islands, the Gulf coast of Mexico, the 
northern part of the Atlantic coast of South America, and a 
limited section of the west coast of Africa constitute the present 
home of yellow fever. From this area (the so-called " yellow- 
fever zone ") the disease is frequently transported to contiguous 
or distant countries. The South Atlantic and Gulf coasts of the 
United States and the shores of the Caribbean Sea are most 
liable to the epidemic visitation of this pestilence. 

The first trustworthy account of an epidemic of yellow 
fever dates from the year 1635, when it prevailed on the Island 
of Guadeloupe. This and the adjoining islands of Dominica, 
Martinique, and Barbadoes were invaded a number of times in 
the fifty years following the above date. Jamaica was invaded 
in 1655 and Domingo the year after. In 1693 the first appear- 
ance of the disease is mentioned in the United States, being 
observed in Boston, Philadelphia, and Charleston. In 1699 it 
appeared as an epidemic in Vera Cruz, and re-appeared in Phila- 
delphia and Charleston. Since the year 1700, the disease has 



332 • TEXT-BOOK OF HYGIENE. 

appeared in an epidemic form, at one or more places within th( 
present limits of the United States, eighty times, the last consid- 
erable invasion being at Jacksonville and other places in Florida 
and Decatnr in Alabama, in 1888. 

In South America yellow fever appeared for the first tim< 
in 1740. In 1819 the disease was imported into Brazil, am 
has since then been endemic. Peru and the Argentine Republii 
have also suffered several severe visitations of vellow fever sinci 
1854. 

On the west coast of Africa, yellow fever «eems to be en 
demic in the peninsula of Sierra Leone, where it has been fre 
quently observed since 1816. It has also prevailed epidemicalb 
in Seneoambia and a number of the islands off the northeri 
portion of the west African coast. In Europe, Spain and Por 
tugal have been the only countries to suffer from yellow-feve: 
epidemics. 

Although tlie causes of yellow fever cannot be definiteb 
stated, it is well-known that it only occurs endemically withii 
the tropics, and prevails epidemically elsewhere only during the 
Slimmer. Of 180 epidemics observed in the United States anc 
Bermudas, 154 began in July, August, and September. Of the 
remaining 26, none began in the six months from November t( 
April. 

A temperature of 26° C. and a high humidity are gener 
ally considered essential to produce an outbreak of the disease 
Of other necessary meteorological conditions nothing is known 

That the specific cause of yellow fever is a micro-organisn 
appears probable from a consideration of the clinical history of 
the disease and its mode of propagation. Up to the presen 
time, however, none of the various organisms described as causa- 
tive have made good the claims advanced by their discoverers 
It can be stated without reserve that neither the organism of 
Freire, of Carmona, of Babes, of F. S. Billings, of Finlay, or of 
Gibier, is the true cause of yellow fever. 

It seems to be well established that the most filthy ant 



YELLOW FEVER. 333 

insanitary portions of cities are tliose principally ravaged by 
yellow fever. The author is convinced from personal observa- 
tion in Savannah, Memphis, and New Orleans, that filth is one 
of the principal factors in the spread of yellow fever. This 
opinion is also forcibly expressed by many of the most eminent 
authorities on the subject. 

Yellow fever is not endemic within the limits of the United 
States, and has probably never originated here. The instances 
in which it has appeared to do so may be explained by the per- 
sistence of the morbific agent through one or more winters, or 
by a new importation which has escaped observation. 

Yellow fever frequently breaks out on shipboard and causes 
much loss of life. There is no evidence that it originates on 
ships ; it is only acquired after intercourse with an infected ship 
or infected place. 

The question of the personal contagion of yellow fever has 
been decided negatively. The disease is infectious and its cause 
may be transported in fomites, but persons sick with the disease 
do not communicate it. An infected atmosphere, or one favor- 
able to the poison, is necessary to the propagation of the disease. 

The preventive measures indicated against yellow fever 
appear from the foregoing: they are strict sanitary inspection to 
prevent the introduction of a person sick with the disease; to 
prevent the introduction of clothing or other fomites from a 
suspected locality without thorough disinfection, and such a con- 
dition of public and private sanitation as will prevent the devel- 
opment of the poison, should the latter, perchance, be introduced. 

When the disease becomes epidemic in a city, the inhabi- 
tants should be removed to temporary camps beyond the infected 
area. The experience of the city of Memphis in 1879, and of 
various localities in Florida in 1888, encourages the hope that 
by prompt depopulation of cities and strict enforcement of sani- 
tary measures in the camps the terrors of yellow fever can be 
largely averted. The sick should be promptly isolated, and no 
one except attendants permitted to have intercourse with them. 



334 TEXT-BOOK OF HYGIENE. 

SCARLET FEVER AND MEASLES. 

The early history of these two contagious eruptive fevers is 
inextricably blended together. Up to the latter half of the 
seventeenth century the distinction between the two was not 
made by writers. Sydenham was among the first who clearly 
separated scarlet fever from measles and gave it a distinct name. 
Since the great English Hippocrates, the essential character of 
scarlet fever has been recognized by all physicians, and it is now 
never, or but rarely, confounded with measles. 

Of the two diseases, measles is somewhat more generally 
prevalent, although both occur usually in epidemics. There is 
hardly a country in which measles has not been observed, while 
the continents of Asia and Africa have remained measurably 
exempt from scarlet fever up to the present time, although epi- 
demics have been recorded in India and Japan. 

Hirsch states that scarlet fever was first observed in this 
country in 1735, at Kingston, Mass., quoting as authorities Dr. 
Douglass, of Boston, and Dr. Golden, of New^ York. The 
latter, however, in a letter to Dr. Fothergill,-^ clearly describes 
diphtheria, and not scarlet fever. Its distribution is now general, 
but it is said to be much milder in the southern than in other 
portions of the United States. The prevalence of measles is not 
limited to any geographical section. 

Epidemics of measles usually begin during cold weather. 
Of 530 epidemics observed in Europe and North America, 339 
occurred during the colder and 191 during the warmer months. 
In 213 of these, the height of the epidemic occurred 135 times 
in winter and spring, and only 78 times during summer and 
autumn. Scarlet fever epidemics occur more frequently in 
autumn than at any other season. 

The cause of scarlet fever or of measles is not to be 
sought in climatic influences, insanitary surroundings, or special 
natural conditions of air, water, or soil. Both diseases are 
contagious and infectious, and the contagion is transmitted either 

* Medical Observations and Inquiries, vol. i, p. 211. London, 1776. 



DIPHTHERIA. 335 

by fomites (clothing, letters, etc.), infected air, drinking-water, 
or milk. 

Several observers have claimed the discovery of the specific 
organism of scarlet fever, but no trustworthy evidence has yet 
been furnished that the problem is solved. On a previous page 
(93) reference has been made to the probable connection between 
a disease of milk-cattle and scarlet fever. 

The measures for the prevention of both diseases are isola- 
tion and thorough disinfection. 

DIPHTHERIA. 

Under the names of Syriac and Egyptian ulcers, Aretseus, 
a writer of the second century, described various forms of malig- 
nant sore throat. The disease now called diphtheria prevailed at 
various places in Europe during the Middle Ages. In this country 
it was first observed about the middle of the last century, and 
in 1771 Dr. Samuel Bard, of New York, described it very 
accurately. Although repeated severe outbreaks occurred in 
Europe in the early part of the present century, it was not until 
1857 that it again attracted attention by its epidemic prevalence 
in the United States. Since that time it has spread throughout 
the country, and is at present one of the most generally diffiised, 
as well as one of the most fatal, of the contagious diseases. In 
certain epidemics its malignancy is very marked, while in others 
it seems to be a rather mild affection. 

Diphtheria is personally contagious ; it may be transmitted 
by inoculation, as well as by inhaling an infected atmosphere. 
The virus is supposed by some investigators to dwell in a micro- 
organism, but no agreement has been reached as to the character 
of the specific microbe.^ 

The question as to the identity of diphtheria and croup is 
not merely a clinical one, but has an important bearing upon 
preventive medicine. If croup is a non-contagious and non- 
infectious disease, as is held by many, no precautions will be 

* "Wood and Formad, Klehs and Loffler, Emmericli, and T. Mitchell Prudden. 



336 TEXT-BOOK OF HYGIENE. 

necessary to prevent its spread to healthy persons. If, on the 
other hand, diphtheria and croup are identical in nature, the 
danger of infection is equally great in both diseases. Inasmuch 
as it is frequently impossible to positively decide upon a diagnosis, 
it would be well to consider the identity of the two diseases as 
established, and act, as far as preventive measures are concerned, 
as if all were cases of diphtheria. 

Diphtheria is inoculable upon animals, and may through 
this medium be transmitted to man. 

Persons sick with diphtheria should be carefully isolated ; 
no one but the immediate attendants should be allowed to come 
in contact with the patients. Table utensils, bedding, and cloth- 
ing used by the sick should be thoroughly disinfected by steam 
or boiling water before being used by others. Intimate contact 
with the sick, such as kissing, should be strictly prohibited. 
There seems no room to doubt that the virus of the disease can 
also be carried in the clothing. Hence, physicians and nurses 
should be especially careful in personally disinfecting themselves 
after contact with a case of diphtheria. After death or recovery 
of the patient, the apartment occupied during the illness should 
be disinfected with chlorine or sulphurous-acid gas. 

Children recovering from diphtheria, scarlet fever, measles, 
or small-pox, should not be permitted to attend school for at 
least four weeks after recovery. It is believed that there is 
danger of infection for a period about as long as this, and, besides, 
the patients are apt to be weakened from the effects of the dis- 
ease, and not able to resist the strain of continuous mental effort. 

DENGUE. 

The disease known as break-bone fever, dandy fever, and 
by various other names, was first observed in the United States 
in 1780 by Dr. Benjamin Rush. Dr. Rush describes an epi- 
demic which prevailed during the summer and early autumn of 
that year under the name of " bilious remittent fever," but the 
symptoms of the disease hardly leave any doubt that it was 



DENGUE. 337 

dengue. In 1779 and 1780 it was also observed on the Coro- 
mandel coast, in Egypt, and on the island of Java. In 178^ to 
1788 dengue also prevailed in various cities of Spain. In 1818 
an epidemic appeared in Lima, in which nearly every one of the 
70,000 inhabitants was attacked. 

In 1824-25 the disease again prevailed widely in India, 
where it was known as the " three-day fever." Isolated out- 
breaks occurred in that country until 1853, when it again ap- 
peared as a wide-spread epidemic, and in 1872 anotlier epidemic 
outbreak occurred in the East, extending from Eastern Africa 
to Arabia, India, and China. 

In 1826 an epidemic of dengue appeared in Savannah, and 
in the following two years spread over the southern portion of 
the United States and the AYest Indies, reaching the northern 
coast of South America. In 1845 to 1849 the disease was 
observed in Kio Janeiro ; in 1848 to 1850 in the South Atlantic 
and Gulf States. In 1854 it was observed in Southern Alabama, 
and in the same year in the West Indies. In 1873 another 
epidemic appeared in the lower Mississippi Valley, and in 
1880 an outbreak of some extent occurred in New Orleans, 
Cliarleston, and other places on the Gulf and South Atlantic 
coasts. 

Dengue always begins in the summer or early autumn, and 
ceases abruptly with the advent of cold weather. It is almost 
exclusively limited to hot countries. It spreads with extreme 
rapidity wherever it appears. It is not contagious ; the man- 
ner of its propagation is not known. The susceptibility to the 
disease appears to be almost universal ; it frequently prostrates 
the majority of the inhabitants where an outbreak occurs. 
During the epidemic in Calcutta in 1871-72, 75 per cent, of the 
population were attacked. In the United States similar epi- 
demics have been repeatedly observed. 

Dengue is rarely fatal. It seems to be propagated through 
the atmosphere. No measures of prevention are known or 
available. 

22 



338 TEXT-BOOK OF HYGIENE. 

EPIDEMIC INFLUENZA. 

Accounts of epidemic influenza can be traced back to the 
year 1173, when the disease was observed coincidently in Italy, 
Germany, and England. It has prevailed epidemically, at vary- 
ing intervals, to the present time. In the fourteenth century 
3 epidemics are recorded ; in the fifteenth, 4 ; in the sixteenth, 
7; in the seventeenth, 46. Of these, 15 were very extensive, 
some of them prevailing over both hemispheres contempo- 
raneously. 

On the American continent influenza was first recorded in 
1627, when it prevailed in New England, where it again broke 
out in 1625. Following this there is no notice of the disease 
in America until 1732, when an epidemic began in the New 
England States, which extended over the entire globe. Epi- 
demics occurred during the remainder of the eighteenth cen- 
tury in 1737, 1757, 1761, 1767, 1772, 1781, 1789, and 1798. 
During the present century the disease has prevailed more or 
less extensively in this country at thirteen different times, the 
last epidemic of any considerable extent being in 1879. 

At the time of writing (February, 1890) a very wide- 
spread epidemic, which began in Russia in November, 1889, is 
prevailing in the United States, complicated in many cases by 
pneumonia of a fatal character. The disease manifests itself 
in two principal forms, the catarrhal and the nervous. Weich- 
selbaum, of Vienna, claims to have discovered a micro-organism 
which he believes to be the cause of the affection, but this 
claim has not yet been verified. 

A curious feature of epidemics of influenza is the coinci- 
dent occurrence of outbreaks of a somewhat similar affection 
among animals, horses and dogs being especially attacked. 

Influenza is an acute, specific, infectious disease, not di- 
rectly contagious. The infection is apparently produced or trans- 
mitted in the air. The disease frequently appears over a large 
area of country almost simultaneously. Peculiarities of climate, 
season, meteorological conditions, geological formation, or raci 






EPIDEMIC CEREBRO-SPIXAL MENINGITIS. 339 

characteristics have no apparent influence upon the causation or 
spread of the disease. It occurs more frequently in the winter 
and spring than during the summer or autumnal months. The 
investigation into the epidemic of influenza among horses, re- 
ferred to in a previous chapter/ seems to indicate, however, that a 
moist and impure atmosphere intensifies the disease. 

'No measures of prophylaxis can be indicated except avoid- 
ance of anything tending to depress the vital powers. 

EPIDEMIC CEREBRO-SPINAL MENINGITIS. 

This disease w^as first recognized in Geneva in 1805. In 
the following year it was noted in various places in the United 
States. Both in Europe and this country localized outbreaks 
of the disease occurred between the dates above mentioned and 
1816. At this time the disease seemed to die out altogether, 
but in 1822 it re-appeared in various parts of Europe and 
America. 

Cerebro-spinal meningitis appeared in 1857 in the south- 
west of France, and during the following ten years spread over 
a large part of the country. Algiers, Italy, Denmark, and Ire- 
land were also visited by the scourge. In 1854 and 1861 
Sweden experienced its ravages, and in 1859 Norway was 
invaded by the disease, which continued for nearly a decennium 
in the latter country. From 1860 to 1867 the disease prevailed 
in Holland, Portugal, Germany, Ireland, and Russia. 

After the termination of what may be called the first epi- 
demic, in 1816, cerebro-spinal meningitis was not again observed 
in this country until 1842. In the eight years succeeding, it 
prevailed epidemically throughout almost the whole United 
States. From 1861 to 1873 it was noted frequently in various 
parts of the country. Since the latter year the reports of its 
occurrence in this country have been limited to sporadic cases 
or localized outbreaks. 

Cerebro-spinal meningitis is an acute infectious disease, 

» Chapter I, p. 29. 



340 TEXT-BOOK OF HTGIEXE. 

very fatal in its tendency. It is probably not personally con- 
tagious. Climate has no inHuence upon its origin, but season 
seems to stand in a positive relation to its causation. About 
three-fourths of the epidemics noticed have occurred during the 
winter and spring months. The disease seems to show no 
preterence for peculiarities of topographical or sreographical 
formation. Overcrowding, overwork, and imcleanliness have 
an important influence in determining an outbreak. It is 
especially a disease oi^ youth and adolescence. Out of 975 
cases occurring in Xew York only 150 were ov^r 20 years of 
age, while of the remainder 665 were imder 10. 

The prophylactic measures to be adopted against cerebro- 
spinal meningitis consist in careful attention to the sanitary 
conditions of dwellings and streets, avoidance of overwork and 
overcrowding dining times of epidemic, isolation of the sick, 
and disinfection of the sick-room after the termination of the 
disease. 

STPmus. 

In the year 1494. Charles YJll, of France, in command of 
a larsre army invaded Italy, and early in the following year be- 
sieged Naples. DuriQg the investment of the city a very severe 
disease, characterized by ulcers of the genitals, violent pains in 
the head and limbs, and generalized cutaneous eruptions broke 
out among the besiegers and spread rapidly throughout the 
army and civil popidation. On the return of the army to France, 
al\er the termination of the war, the disease rapidly spread 
throughout Europe, and the Hterature of the early part of the 
sixteenth century, both medical and lay, teems with references 
to it. 

From the locaUty and other circumstances connected with 
its epidemic appearance the disease acquired various names. 
Thus, the French called it morbus XeapoJitanus, or mal d^ItaJie, 
while the Itahans termed it morbus Gallicus, or maJa Franzos, 
At a very early period it was, however, clearly recognized that 
the disease was communicated during sexual intercourse, and 



SYPUILIS. 341 

hence it was usually described in medical writings under tlje 
name Jaes venerea, wliile in the popular literature it still figuR-d 
as the Frenchman's disease ()/?. or ^^/y-s GaUicus). 'J'lie name sijplu.Hs 
was first used in a poem descriptive of the disease, written in 
1521 by Fracastor, a physician of Verona. 

The extraordinary outbreak of the disease toward the end 
of the fifteenth centiu'}- led to many speculations concerning/ its 
origin. As it attacked persons in all ranks and conditions of 
hfe, " sparing neither crown nor cross," in the words of a con- 
temporary poet, the favorite explanation was that meteorol ordeal 
influences had much to do with its causation. Many ascriljed 
it to the malign influence of the stars. The Xeapolitans attrib- 
uted it to the wickedness of their enemies, the French, wliile 
the latter laid the blame on the filth and immoralitv of the 
Italians. The Spaniards claimed tliat it had been imported from 
America by Columljiis, whose first expedition returned to Europe 
in 1493. There are records, however, Avliich prove that the dis- 
ease already existed in Italy in the latter year. In other parts 
of Europe the Jews, who had been driven out of Spain bv the 
terrors of the Inrpiisition, were accused of this, as of manv other 
misfortunes which befell the people. AVhen it Avas definitelv 
established that the disease was communicated almost solelv bv 
sexual mtercourse. the theory of its transatlantic origin became 
very popular. It is characteristic of human nature to refer 
the origin of troubles resulting from its own vices to some other 
source, if possible. This theory of the American origin of 
syphilis is still held by some writers. AAdthin a few years. Dr. 
Joseph Jones, of New Orleans, claims to have found e^'idences 
of syphilitic disease in the skulls and other bones from some of 
the prehistoric Indian mounds in Mississippi. These observa- 
tions of Dr. Jones have, however, not yet been verified by others. 

Although the first great epidemic of syphilis is clearly trace- 
able to the period between the years 1493 and 1496. an ex- 
amination of the older literature reveals many descriptions of 
disease which can only be explained by assuming them to refer 



342 TEXT-BOOK OF HYGIENE. / 

to syphilis. The Old Testament Scriptures contain numerous 
references to diseases of the genital organs. In most instances 
these troubles are ascribed to the wrath of God, although in 
some cases a pretty shrewd hint is given as to the causation of 
the aifections. Finaly^ remarks that the Hebrew word trans- 
lated in all versions of the Bible by " flesh" signifies also the 
virile member. In this light, the references in Leviticus, XIII- 
XV; Numbers,XXV, 1-9, XXXI, 16-18; Deuteronomy, IV, 3; 
Joshua, XXII, 17 ; I Samuel, V, 6, 9, 12 ; Psalms, CVI, 28-30 ; 
.1 Corinthians, X, 8; Ephesians, II, 11 ; and Colossians, II, 13, 
receive a new interpretation. Numerous innuendoes in the 
Latin classics, and more or less exact descriptions in the medical 
writings of Greece, Rome, China, and India, leave no room for 
doubt that venereal diseases, and probably among them syphilis, 
have existed from the earliest times. 

At the present day syphilis is the most widely prevalent of 
all contagious diseases. In 1873 Dr. F. R. Sturgis estimated 
that in New York 1 person out of every 18 suffered from it. 
This is considered a moderate estimate. Dr. J. Wm. White, 
of Philadelphia, pronounces the opinion that "not less than 
50,000 people of all classes in that city are affected with syphilis." 
On this basis Gihon estimates the number of syphilitics in the 
United States at one time at 2,000,000.^ 

The disease is transmitted, in the vast majority of cases, 
during the performance of the sexual act, but there are numerous 
other ways in which it may be and frequently is communicated. 
In the special literature of the subject are records of many cases 
in which the disease was acquired through a kiss, a bite, the act 
of suckling (from infant to nurse, and conversely), using a pipe, 
glass-blowers' mouth-piece, the finger of a midwife, the instru- 
ments of the dentist or surgeon, inoculation of syphilitic secretion 
mixed with saliva in the process of tattooing, and many other 
ways. Numerous cases have been reported where physicians were 
inoculated on the finger while examining a syphilitic patient. 

1 Arch. 1 Dermat. u. Syphilis, II Jahrg. 1 Heft., p. 126. 

» The Prevention of Venereal Diseases by Legislation, Sanitarian, June, 1882. 



DISEASES OF ANIMALS COMMUNICABLE TO MAN. 313 

The prophylactic measures which suggest themselves from 
a consideration of tlie nature of the disease are isolation of those 
infected, regular inspection of the class of persons through whom 
the disease is most frequently transmitted, i.e., prostitutes, and 
individual precautions against acquiring it. Greater attention 
to cleanliness of the genital organs on the part of those indulg- 
ing in promiscuous intercourse would aid largely in reducing 
^ the number of cases of syphilis. 

DISEASES OF ANIMALS COMMUNICABLE TO MAN. 

SJieep'iJoch. — This is a highly contagious and infectious 
disease of sheep, resembling, in its symptoms, course, and fatality, 
small-pox as it occurs in the human race. It is believed by 
EolUnger to be different from the form of small-pox produced 
in sheep, goats, horses, and other animals by the inoculation of 
Jiuman small-pox. Sheep-pock can be inoculated upon other 
animals and man, but only produces a local disease at the point 
of inoculation in the latter. Sheep may be protected against 
this disease by inoculation with sheep-pock virus (ovination), or 
by vaccination with vaccine lymph. The peculiarity of sheep 
vaccinia is that it is a more or less generalized disease, the 
pustules being distributed over the body. Sheep-pock, when 
inoculated upon human beings, does not produce a generalized 
infectious disease, but remains entirely local. 

Actinomycosis. — Veterinarians have frequently observed a 
disease attacking the jaws of cattle and producing tumors, often 
with ulcerated surfaces. The bone is usually involved. The 
disease has heretofore been generally considered a sarcomatous 
growth. It is not seldom observed among the cattle in the 
western stockyards, where it is known in the vernacular as 
" swell-head." Kecent investigations by Poniick have shown 
that the growth consists of a vegetable parasite (actinomyces), 
and that it is inoculable upon other animals, and may be 
conveyed to man. A considerable number of cases have been 
observed in human beings in Germany, where the disease was 



O-i-i TEXT-BOOK OF niGIEXE. 

lirst described by Poniick, and very recently 4 cases have 
been reported in this country.^ 

Bovine 2\d)e}TiiIosis (Perlsucht). — In cattle, tuberculosis 
occurs in two forms, miliary tubercles and cheesy masses in the 
lungs, and tirm, pearly nodules on the serous membranes. 
These nodules do not break down, but may become calciiied. 

Bovine tuberculosis is a frequent disease among cows kept 
in damp. dark, and ill-ventilated stables. The disease, which is 
essentially the same as human tuberculosis, tubercle bacQli 
being present in the neoplasms, is believed by many to be trans- 
missible to human beings by means of the milk or iiesh of 
tuberculous animals. The sale of the meat of tuberculous cattle 
should be prohibited. 

Babies. — Hydrophobia in the brute, and its comnnmi- 
cability to man through a bite, has been known from the 
remotest antiquity. It occurs in dogs, foxes, wolves, horses, 
and other animals, and may be transmitted from any of them to 
human beings. 

The contagium of rabies, the infective poison, is contained 
principally in the saliva, and is usually inoculated by the teeth 
of the mad animal. 

Pasteur has shown that the greatest ^*irulence of the rabies 
poison resides in the bi*ain and spinal cord of the animal suiier- 
ing from the disease. By cultivation of this virus, the nature 
of which has not yet been delinitely determined, its virulence 
could be diminished, and by inoculation of men and animals 
with the attenuated virus protection ag^iinst the disease could 
be secured. The lact seems likewise establislied tliat the period 
of incubation of the inoculation-nibies is much shorter than that 
acquired in the usual way by bites of i^abid animals. Hence, 
inoculation with the attenuated ^irus protects the bitten individ- 
ual against the flital outbreak of the unmodified disease. 

Anthrax. — Anthrax, or splenic fever (milzbmnd), is an 

» Boston Med. and Sur^. Journnl. Oct. 16. 1SS4, p. 377, and Journ. Am. Med. Ass'n, Nov. >T, 
ISSd. Also, N'. E. Med. Moutlily, Sept. 15, 1SS6. 



DISEASES OF ANIMALS COMMUNICABLE TO MAN. 345 

acute, liiglily contagious and infectious disease of herbivorous 
animals, which may be transmitted by inoculation or the 
ingestion of the virus to other animals and to man. 

The disease is due to a minute vegetaljle organism ^v]^lr•]^ 
is found in the blood and tissues of the diseased animals. 1 his 
organism, hacillus anthracis, ^vas first discovered bv Pollender, 
and has been thoroughly investigated by Uavaine, Pasteur, 
Koch, and others. 

Inoculation of these bacilli or their spores always produrcs 
the disease in susceptible animals. Skins of animals not in fre- 
quently contain the virus, Avhicli may then gain access to the 
blood of persons engaged in handling them. Knackers, 
butchers, wool-sorters, and other persons liable to come in 
contact with sick animals, or handling tlieir fie-li or hides, are 
sul^ject to the mfection, either by direct inoculation (tliron,::!! 
abrasions of the skin, etc.) or by inhalation of the spores of the 
bacillus. An intestinal form of anthrax in man, mycosis iiiies- 
tinalis. is sometimes produced by the consumption of meat of 
animals suffering, when killed, of splenic fe\'er. Xumeroiis 
instances have been reported. The diagnosis has been verified 
by discovering the bacillus of anthrax in the blood and various 
organs of the individuals attacked. 

In view of the dangerous character of the disease, persons 
coming in contact with animals suftering from anthrax should 
be warned of their peril. In order to protect oilier animals in 
a herd, strict isolation of the infected, tliorough di-infection of 
the stables occupied by them, and deep interment of the cadavers 
of those dead from the disease are indicated. 

Glanders. — Glanders, or farcy, is a very fatal contagious 
disease of horses which may be communicated to other animals 
and to man. The cause of glanders has recently been di-covered 
bv Loffler to be a bacillus resemblinsr the bacillus tuberculosis. 
Pure cultures of this bacillus were inoculated into animals, and 
followed by glanders in a number of the cases. 

The infection in man may occur either upon the seat of 



346 TErr-BOOK of hygiene. 

excoriations of the skin or mucous membranes, especially those 
of the nose, conjunctiva, and possibly by inhalation of infective 
particles floating in the air. 

Animals with glanders should be promptly killed and their 
cadavers cremated or deeply buried. No part of the body of 
any animal dead with glanders should be allowed to be used. 
Infected stables should be thoroughly disinfected. 

[The works of especial value to students who desire fuller 
information upon the subjects treated in this chapter are the 
following : — 

Hirscli, Handbuch der Historisch-Geograpliischen Pathologie, 2te 
Aufl., Stuttgart, 1883. — Hseser, Geschichteder Epidemischen Krankheiten. 
— Hecker, The Black Death, translated by B. G. Babingtoii. — Defoe, Jour- 
nal of the Plague in London. — Rolilfs, Die Orientalische Pest. — Marson, 
Small-pox, in Reynolds's System of Medicine, vol. i. — Seaton, Yaccina- 
tion, ibid. — Trousseau, Clinical Medicine, vol. i. — Fifth Annual Report 
Illinois State Board of Health. — Hardaway, Essentials of Vaccination. — 
Crookshank, History and Pathology of Yaccination. — Woodworth and 
McClellan, Cholera Epidemic in United States in 1873. — Chaille, Report 
of Yellow Fever Commission, Annual Report National Board of Health for 
1880. — Wood and Formad, Memoir on the Nature of Diphtheria, ibid.^ 
1882. — Thompson, Annals of Influenza. — Stille, Epidemic Meningitis. — 
Mueller, Die Yenerischen Krankheiten im Altherthum. — Lancereaux, 
Traite de la Syphilis. — Bollinger, Ueber Menschen u. Thierpocken, etc., 
Samml. Klin. Yortr., No. 116. — Ponfick, Die Actinomycose des Men- 
schen. — Gamgee, Hydrophobia and Glanders, in Re3aiolds's System of 
Medicine, vol. i. — Bollinger, Anthrax, in Ziemssen's Cyclopaedia, vol. iii.] 



CHAPTEK XX. 

Antiseptics, Disinfectants, and Deodorants. 

Much confusion exists in the popular mind, and even 
among physicians, as to the exact meaning of the terms at the 
head of this chapter. By many they are used synonymously, and 
hence frequently give rise to ambiguity and misunderstanding. 

Antisepsis, which is so frequently confounded with disin- 
fection, should be more accurately defined than is usual by 
writers. An antiseptic is an agent which retards, prevents, or 
arrests putrefaction, decay, or fermentation. It does not neces- 
sarily destroy the vitality of the organisms upon which these 
processes depend. An antiseptic may also arrest the develop- 
ment of the organisms which cause infectious diseases, and may 
hence be used as a preventive of such diseases. But antiseptics 
do not destroy the life of disease-germs, and hence cannot be 
relied upon when such organisms are present. 

By disinfection, in the proper and restricted use of the term, 
is meant the destruction of the specific infectious material which 
causes infectious diseases. If the view is accepted that all in- 
fectious diseases are due to micro-organisms or germs, then a 
disinfectant is equivalent to a germicide. In sanitary practice 
and experimental investigations this view is, in fact, adopted. 
In testing the action of various disinfecting agents upon infec- 
tious material, the biological test is the one universally relied 
upon by experimenters, and no observations upon disinfection 
based upon chemical tests alone would be accepted by sanitarians 
as conclusive. It may therefore be assumed for practical pur- 
poses that no agent can be accepted as a disinfectant if it is not 
also a germicide. From this it follows that disinfection, to be 
trustworthy, must be thorough. " There can be no partial 
disinfection of infectious material ; either its infectious power is 
destroyed, or it is not. In the latter case there is a failure to 
disinfect."^ Obviously, also, there can be no disinfection in the 

* Report of Co:nmittee on Disinfectants of the American Public Health Assoc:ation,p. 236. 

(3i7) 



348 



TEXT-BOOK OF HYGIENE. 



absence of infectious material. Faecal discharges, a diseased 
body or corpse, clothing, bedding, an apartment, a ship, or a 
hospital ward may or may not be infected. In the former case 
we may speak of disinfecting them ; in the latter, it would be an 
inappropriate use of the word. 

Confusion is also liable to arise by considering disinfectants 
and deodorizers as synonymous. Deodorants merely remove 
offensive odors, and may not possess any disinfecting power 
whatever. Thus, one of the most efficient disinfectants at our 
command (mercuric chloride) is not a deodorizer at all, except 
by preventing putrefaction. On the other hand, some of the 
most effective deodorants have only a subordinate position in the 
scale of disinfectants. 

Careful investigations have shown that there is a wide 
divergence between various disinfecting agents in their influence 
upon disease-germs, some being efficient in high dilutions, while 
others require to be brought in contact with the germs in great 
concentration. For example, mercuric chloride will act as an 
efficient poison to certain disease-germs (anthrax spores) in tlie 
proportion of 1 to 1000, while zinc-chloride must be used in the 
proportion of 1 to 5 (or 20 per cent.). 

It has been, further, discovered that different disease-germs 

present varying resisting power to the same disinfecting agent, 

some being easily destroyed, while others are much more resistant. 

For example, the following table shows a number of experiments 

made by Dr. Meade Bolton for the American Committee on 

Disinfectants : — 

Table XXYII. 



Organism. 


Chloride of 
Lime. 


Mercuric 
Chloride. 


Carbolic Acid. 


Typhoid bacillus 

Cliolera spirillum .... 
Anthrax spores 

Staphylococcus aureus . . . 
Staphylococcus citreus . . 
Staphylococcus albus . . . 


1 : 2000 
1 : 2000 
1:100 

1:200 

1:50 

1:200 


1:10,000 
1:10,000 
1:1000 


1:100 
1:100 

1:50 

(Uncertain.) 

1:100 
1:100 
1:100 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 349 

Assuming that infectious diseases are caused by micro- 
organisms, and that these are different from the micro-organisms 
of ordinary decay or putrefaction, it can be readily understood 
that the processes of organic decomposition may themselves act 
as disinfectants. It is known, for example, that when a fer- 
menting liquid putrefies, the organisms of fermentation disap- 
pear and give place to the organisms of putrefaction (bacterium 
termo, etc.). So, likewise, the bacilli of anthrax and of tuber- 
culosis are killed by the putrefactive process, if this takes place 
in the absence of free oxygen. Furthermore, the reproduction 
of organisms of a certain kind ceases when certain chemical (]) 
changes take place in their environment. Fermentation in a 
saccharine liquid ceases and the ferment-organisms die when the 
accumulation of the product of the fermentation (alcohol) has 
reached a certain proportion, although there may still be un- 
decomposed sugar present. In like manner it is intelligible that 
the products of micro-organisms may eventually destroy their 
producers, and so place a limit to the morbid process. The 
specific cause of small-pox, yellow fever, cholera, and similar 
infectious diseases is rapidly destroyed when decomposition of 
the corpses of those dead with such diseases sets in. Hence, 
the reason why infectious diseases are not spread from cemeteries. 

From the foregoing it may be gathered that disinfection 
consists chiefly in a struggle against organized disease-germs.^ 
As, however, experiments and observations have shown that the 
life-history of disease-germs varies with the different organisms 
involved, it becomes evident that specific directions concerning 
disinfection can be given only when the life-history of the 
specific organism is known. 

The American Committee on Disinfectants, to whose work 
reference has already been made, divides disinfectants into two 
classes : those efficient for the destruction of infectious material 
containing spores, and those which will destroy infectious ma- 
terial only in the absence of spores. The recommendations of 

1 Mueller und Falk, in Realencyclopsedie d, ges. Heilk., Bd. IV., p. 62. 



350 TEXT-BOOK OF HYGIENE. 

the committee, covering not only the appropriate disinfectant to 
be used for the destruction of the organisms, but also the con- 
ditions under which the agent should be used, are as follow : — 

The most useful agents for the destruction of sj^ore-containing 
infectious material are : — 

1. Fire. Complete destruction by burning. 

2. Steam under pressure. 105° C. (221° F.) for ten minutes. 

3. Boiling in water for half an hour. 

4. Chlorinated lime^ A 4:-per-cent. solution. 

5. Mercuric chloride. A solution of 1 to 600. 
For the destruction of infectious material which owes its infecting 

power to the presence of micro-organisms not containing spores, the 
committee recommends : — 

1. Fire. Complete destruction by burning. 

2. Boiling in water for ten minutes. 

3. Dry heat. 110° C. (230° F.) for two hours. 

4. Chlorinated lime. ^ A 2-per-cent. solution. 
6. Solution of chlorinated soda.^ A 10-per-cent. solution. 

6. Mercuric chloride. A solution of 1 to 2000. 

7. Sulphur dioxide. Exposure for twelve hours to an atmosphere 
containing at least 4 volumes per cent, of this gas in presence of 
moisture.^ 

8. Carbolic acid. A 5-per-cent. solution. 

9. Sulphate of copper. A 5-per-cent. solution. 
10. Chloride of zinc. A 10-per-cent. solution. 

The committee would make the following recommendations with 
reference to the practical application of these agents for disinfecting 
purposes : — 

For Excreta. 

(a) In the sick-room : — 

1. Chlorinated lime in solution, 4 per cent. 
In the absence of spores : — 

2. Carbolic acid in solution, 5 per cent. 

3. Sulphate of copper in solution, 5 per cent. 
(6) In privy-vaults : — 

1. Mercuric chloride in solution, 1 to 500.* 

2. Carbolic acid in solution, 5 per cent. 

» Should contain at least 25 per cent, of available chlorine. 

" Should contain at least 3 per cent, of available chlorine. 

3 This will require the combustion of between 1>^ to 2 kilogrammes of sulphur for every 
28 cubic metres of air-space. 

* The addition of an equal quantity of potassium permanganate as a deodorant, and to 
give color to the solution, is to be recommended. 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 351 

(c) For the disinfection and deodorization of the surface of masses 
of organic material in privy-vaults etc.: — 
Chlorinated lime in powder. 

For Clothing, Bedding, etc. 

(a) Soiled underclothing, bed-linen, etc.: — 

1. Destruction by fire, if of little value. 

2. Boiling for at least half an hour. 

3. Immersion in a solution of mercuric chloride of the strength 
of 1 to 2000 for four hours. 

4. Immersion in a 2-per-cent. solution of carbolic acid for four 
hours. 

(b) Outer garments of wool or silk, and similar articles, which 
would be injured by immersion in boiling water or in a disinfecting 
solution : — 

1. Exposure in a suitable apparatus to a current of steam for 
ten minutes. 

2. Exposure to dry heat at a temperature of 110° C. (230° F.) 
for tw^o hours. 

(c) Mattresses and blankets soiled by the discharges of the sick : — 

1. Destruction by fire. 

2. Exposure to superheated steam (105° C. = 221° F.) for ten 
minutes. (Mattresses to have the cover removed or freely 
opened.) 

3. Immersion in boiling water for half an hour. 

Furniture and Articles of Wood, Leather, and Porcelain. 

Washing, several times repeated, with solution of carbolic acid, 2 

per cent. 

For the Person. 

The hands and general surface of the body of attendants of the 
sick, and of the convalescents, should be washed with — 

1. Solution of chlorinated soda diluted with nine parts of 
water (1 to 10). 

2. Carbolic acid, 2-per-cent. solution. 

3. Mercuric chloride, 1 to 1000. 

For the Dead. 
Envelop the body in a sheet thoroughlj^ saturated with — 

1. Chlorinated lime in solution, 4 per cent. 

2. Mercuric chloride in solution, 1 to 500. 

3. Carbolic acid in solution, 5 per cent. 



352 TEXT-BOOK OF HYGIENE. 



'^H 



For the Sick-room and Hospital Wards. 

(a) While occupied, wash all surfaces with — 

1. Mercuric chloride in solution, 1 to 1000. 

2. Carbolic acid in solutio'n, 2 per cent. 

(b) When vacated : — 
Fumigate with sulphur dioxide for twelve hours, burning at least l-J 

kilogrammes sulphur for every 28 cubic metres of air-space in the room ; 
then wash all surfaces with one of the above-mentioned disinfectinor 
solutions, and afterward with soap and hot water ; finally throw open 
doors and windows and ventilate freely. 

For Merchandise and the Mails. 

The disinfection of merchandise and of the mails will only be 

required under exceptional circumstances ; free aeration will usuallj- be 

sufficient. If disinfection seems necessary, fumigation with sulphur 

dioxide will be the onl}^ practicable method of accomplishing it without 

injury. 

Rags. 

(a) Rags which have been used for wiping away infectious discharges 
should at once be burned. 

(b) Rags collected for the paper-makers during the prevalence of 
an epidemic should be disinfected, before they are compressed in bales, 

by- 

1. Exposure to superheated steam (105° C.= 221° F.) for ten 

minutes. 

2. Immersion in boiling water for half an hour. 

Ships. 

(a) Infected ships at sea should be washed in every accessible place, 
and especially localities occupied by the sick, with — 

1. Solution of mercuric chloride, 1 to 1000. 

2. Solution of carbolic acid, 2 per cent. 

The bilge should be disinfected by the liberal use of a strong 
solution of mercuric chloride. 

(b) Upon arrival at a quarantine station, an infected ship should at 
once be fumigated with sulphurous-acid gas, using 1^ kilogrammes of 
sulphur for every 28 cubic metres of air-space ; the cargo should then 
be discharged on lighters ; a liberal supply of the concentrated solution 
of mercuric chloride (1 to 32) should be thrown into the bilge, and at the 
end of twenty -four hours the bilge-water should be pumped out and 
replaced with pure sea-water ; this should be repeated. A second fumi- 
gation after the removal of the cargo is recommended. All accessible 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 353 

surfaces should be washed with one of the disinfecting solutions here- 
tofore recommended, and subsequently with soap and hot water. 

For Railway-cars. 
The directions given for the disinfection of dwellings, hospital 
wards, and ships applj- as well to infected railwaj^-cars. The treatment 
of excreta with a disinfectant before they are scattered along the tracks 
seems desirable at all times, in view of the fact that the}' may contain 
infectious germs. During the prevalence of an epidemic of cholera this 
is imperative. For this purpose the standard solution of chlorinated 
lime is recommended. 

From the foregoing it would appear tliat heat, chlorinated 
lime, mercuric chloride, solution of chlorinated soda (Labar- 
raque's solution), carbolic acid, sulphate of copper, zinc chloride, 
and sulphur dioxide (sulphur -fumes) are the most generally 
available disinfectants. 

The following " general directions " for the practical appli- 
cation of disinfection are given by the committee : — 

Disinfection of Excreta^ etc. — The infectious character of the dejec- 
tions of patients suffering from cholera and typhoid fever is well estab- 
lished ; and this is true of mild cases and of the earliest stages of these 
diseases, as well as of severe and fatal cases. It is probable that epidemic 
dj'sentery, tuberculosis, and perhaps diphtheria, 3'ellow fever, scarlet 
fever, and tj^phus fever ma}" also be transmitted by means of the alvine 
discharges of the sick. It is, therefore, of the first importance that these 
should be disinfected. In cholera, diphtheria, 3'ellow fever, and scarlet 
fever all vomited material should also be looked upon as infectious. 
And in tuberculosis, diphtheria, scarlet fever, and infectious pneumonia 
the sputa of the sick should be disinfected or destro^'ed by fire. It seems 
advisable, also, to treat the urine of patients sick with an infectious 
disease with one of the disinfecting solutions below recommended. 

Chloride of lime, or bleaching powder, is perhaps entitled to the first 
place for disinfecting excreta, on account of the rapidity of its action. 
The following standard solution is recommended : — 

Dissolve chloride of lime {chlorinated lime, bleaching powder) of the 
best quality'^ in pure water in the proportion of 6 ounces to the gallon 
{4.0 grammes to the litre). 

Use 1 quart (1 litre) of this solution for the disinfection of each dis. 
charge in cholera, typhoid fever, etc.^ Mix well, and leave in the vessel 

* Good chloride of lime should contain at least 25 per cent, of available chlorine. 
'For a very copious discharge use a larger quantity. 



354 TEXT-BOOK OF HYGIENE. 

for at least one hour before throwing into priv^^-well or water-closet. 
The same directions appl}^ for the disinfection of vomited matters. 
Infected sputum should be discharged directly into a cup half full of the 
solution.! A 5-per-cent. solution of carbolic acid ma}^ be used instead 
of the chloride-of-lime solution, the time of exposure to the action of the 
disinfectant being four hours. 

Disinfection of the Person. — The surface of the bod}^ of a sick person 
or of his attendants, when soiled with infectious discharges, should be at 
once cleansed with a suitable disinfecting agent. For this purpose, solu- 
tion of chlorinated soda (liquor sodse chlorinatse — Labarraque's solution) 
diluted with 9 parts of water, or the standard solution of chloride of lime 
diluted with 3 parts of water, may be used. A 2-per-cent. solution of 
carbolic acid is also suitable for this purpose, and under proper medical 
supervision the use of a solution of corrosive sublimate (1 to 1000) is to 
be recommended. 

In diseases like small-pox and scnrlet fever, in which the infectious 
agent is given off from the entire surface of the bodj^, occasional ablu- 
tions with the above-mentioned solution of chlorinated soda are recom- 
mended. 

In all infectious diseases the body of the dead should be enveloped 
in a sheet saturated with the standard solution of chlorinated lime, or 
with a 5-per-cent. solution of carbolic acid, or a 1 to 500 solution of cor- 
rosive sublimate. 

Disinfection of Clothing. — Boiling for half an hour will destroy the 
vitality of all known disease-germs, and there is no better wa^^ of dis- 
infecting clothing or bedding wiiich can be washed than to put it 
through the ordinary operations of the laundr3^ No dela^^ should occur, 
however, between the time of removing soiled clothing from the person 
or bed of the sick and its immersion in boiling water, or in one of the 
following solutions until this can be done : — 

Corrosive sublimate, 1 gramme to the litre (1 to 1000), or carbolic 
acid (pure), 8 grammes to the litre. 

The articles to be disinfected must be thoroughly soaked with the 
disinfecting solution and left in it for at least two hours, after which they 
may be wrung out and sent to the wash.^ 

Clothing or bedding which cannot be washed should be disinfected 

• Recently a small spitting-cup made of stiff paper has been introduced especially for tlie 
use of consumptives. The cup is carried about by the patient or kei>t within reach. When the 
cup has been in use for a time, and before the sputa can become desiccated, it is thrown into the 
fire and burned. 

"^ Solutions of corrosive sublimate should not be placed in metal receptacles, for the saltia 
decomposed and the mercury precipitated by contact with copper, lead, or tin. A wooden tub 
or earthen crock is a suitable receptacle for such solutions. 



ANTISEPTICS, DISIXFECTAXTS, AXD DEODORANTS. 355 

b}' steam in a properl^'-constructed disinfection cliamber. In the absence 
of a suitable steam disinfecting apparatus, infected clothing and bedding 
should be burned. 

Disinfection of the Sick-room. — In the sick-room no disinfectant can 
take the place of free ventilation and cleanliness. It is an axiom in sani- 
tary- science that it is impracticable to disinfect an occupied apartment 
for the reason that disease-germs are not destroj-ed by the presence in 
the atmosphere of an^- known disinfectant in respirable quantity. Bad 
odors ma}- be neutralized, but this does not constitute disinfection in the 
sense in which the term is here used. These bad odors are, for the most 
part, an indication of want of cleanliness or of proper ventilation, and it 
is better to turn contaminated air out of the window or up the chimney 
than to attempt to purify it by the use of volatile chemical agents, such 
as carbolic acid, chlorine, etc., which are all more or less offensive to the 
sick, and are useless so far as disinfection — properl}" so called — is con- 
cerned. 

When an apartment which has been occupied hy a person sick with 
an infectious disease has been vacated, it should be disinfected. The 
object of disinfection in the sick-room is mainl}^ the destruction of infec- 
tious material attached to surfaces or deposited as dust upon window- 
ledges, in crevices, etc. If the room has been properly cleansed and 
ventilated while still occupied by the sick person, and especially if it 
was stripped of carpets and unnecessar}^ furniture at the outset of his 
attack, the difficulties of disinfection will be greatly reduced. 

All surfaces should be thorough^ washed with the standard solu- 
tion of chloride of lime, diluted with 3 parts of water, or with 1 to 1000 
solution of corrosive sublimate. The walls and ceiling, if plastered, 
should be subsequently treated with a lime-wash. Especial care must 
be taken to wash awa}^ all dust from window-ledges and other places 
where it may have settled, and thoroughly to cleanse crevices and out- 
of-the-way places. After this application of the disinfecting solution, 
and an interval of twenty-four hours or longer for free ventilation, the 
floors and wood-work should be well scrubbed with soap and hot water, 
and this should be followed by a second, more prolonged exposure to 
fresh air, admitted through open doors and windows. 

As an additional precaution, fumigation with sulphurous-acid gas is 
to be recommended, especially for rooms which have been occupied b}- 
patients with small-pox, scarlet fever, diphtheria, tj^phus fever and j-el- 
low fever. But fumigation with sulphurous-acid gas alone, as commonly 
practiced, cannot be relied upon for disinfection of the sick-room and its 
contents, including bedding, furniture, infected clothing, etc., as is popu- 
larly believed. 



356 TEXT-BOOK OF HYGIENE. 

When fumigation is practiced, it should precede the general washing 
with a disinfecting solution heretofore recommended. To insure any 
results of value, it will be necessary to close the apartment to be disin- 
fected as completely as possible by stopping up all apertures through 
which the gas might escape, and to burn not less than 3 pounds of 
sulphur for each 1000 cubic feet (IJ kilogrammes to 28 cubic metres) of 
air-space in the room. To secure complete combustion of the sulphur, 
it should be placed, in the form of powder or small fragments, into a 
shallow iron pan, which should be set upon a couple of bricks in a tub 
partly filled with water, to guard against fire. The sulphur should be 
thoroughly moistened with alcohol before igniting it. 

Disinfection of Privy-vaults^ Cess-pools, etc. — When the excreta 
(not previously disinfected) of patients with cholera or t3'phoid fever 
have been thrown into a privy-vault this is infected, and disinfection 
should be resorted to as soon as the fact is discovered, or whenever there 
is reasonable suspicion that such is the case. It will be advisable to take 
the same precautions with reference to privy-vaults into which the ex- 
creta of 3'ellow fever have been thrown, although we do not definitely 
know that this is infectious material. 

For this purpose the standard solution of chloride of lime may be 
used in quantity proportioned to the amount of material to be disin- 
fected, but where this is considerable it will scarcely be practicable to 
sterilize the whole mass. The liberal and repeated use of this solution, 
or of a 5-per-cent. solution of carbolic acid, v/ill, however, disinfect the 
surface of the mass, and is especially to be recommended during the epi- 
demic prevalence of typhoid fever or of cholera. 

All exposed portions of the vault, and the wood-work above it, 
should be thoroughly washed down with the disinfecting solution. In- 
stead of the disinfecting solutions recommended, chloride of lime in 
powder may be daily scattered over the contents of the priv}^- vault. 

Disinfection of Ingesta. — It is well established that cholera and| 
typhoid fever are \QYy frequently, and perhaps, usuall}^, transmitted ' 
through the medium of infected water or articles of food, and especially 
milk. Fortunatel}^, we have a simple means at hand for disinfecting such 
infected fluid. This consists in the application of heat. The boiling 
temperature maintained for half an hour kills all known disease-germs. 
So far as the germs of cholera, yellow fever, and diphtheria are concerned, 
there is good reason to believe that a temperature considerably below 
the boiling-point of water will destro}^ them. But in order to keep on 
the safe side, it is best not to trust anything short of the boiling-point 
(100° C. = 212° F.) when the object is to disinfect food or drink which is 
open to the suspicion of containing the germs of any infectious disease. 



1 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 



SdT 



During the prevalence of an epidemic of cholera it is well to boil all 
water for drinking purposes. After boiling, the water may be filtered, 
if necessary, to remove sediment, and then cooled with pur^e ice if 
desired. 

The following substances are antiseptics, but in the 
strength given cannot be depended upon as disinfectants : — 



Table XXYIII. 










Thymol, 1 


80,000. 


Bichloride of mercury, 








1 


40,000. 


Oil of mustard, 








1 


33,000. 


Acetate of alumina, 








1 


6310. 


Bromine, 








> . 1 


5597. 


Picric acid, . 








1 


5000. 


Iodine, .... 








1 


4000. 


Sulphuric acid, 








. 1 : 800-1 


: 3353. 


Permanganate of potassium, 








1 


3000. 


Camphor, 








1 


: 2500. 


Eucalyptol, . 








I 


2500. 


Chromic acid, 








. 1 


2200. 


Chloride of aluminum, . 








1 


2000. 


Hydrochloric acid, 








, 1 


1700. 


Benzoic acid, 








, 1 


1439. 


Quinine, .... 








I 


1000. 


Boric acid, .... 








1:200-1 


■800. 


Salicylic acid. 








1 : 200-1 


800. 


Carbolic acid. 










500. 


Sulphate of copper, 












400. 


Nitric acid, . 












400. 


Biborate of soda, . 












200. 


Sulphate of iron, . 












200. 


Creasote, 












200. 


Arsenious acid, 












100. 


Pja-ogallic acid. 












62. 


Tr. chloride of iron. 












25. 


Alcohol, 






. 40 


to 9 


3 per 


cent. 



The agents mentioned in the above list may all be used 
with satisfactory results in surgical and obstetrical practice as 
antiseptics, but it must be borne in mind that the great danger 
in treating wounds comes from carrying infectious particles to 
them in the hands or instruments of the operator. In order to 



358 TEXT-BOOK OF HYGIENE. 

render these aseptic the most thorough measures of disinfection, 
such as heat, strong chemical disinfectants, and physical as well 
as chemical and biological cleanliness are indicated. In a sur- 
gical wound, or in the vagina and uterus of the parturient 
woman, the use of antiseptics is entirely secondary to disinfec- 
tion, under which may primarily be understood rigid cleanliness. 

In public and private sanitation, antiseptics have, as in 
practical surgery, a subordinate importance. / 

Deodorizers are sometimes useful in sanitary practice, but 
care must be taken not to look upon deodorization as equiva- 
lent to disinfection. Among the most useful deodorizers are 
chloride of zinc, chloride of lime, permanganate of potassium, 
and a number of the agents mentioned in Table XXVIII. 

[The following additional works are recommended for 
study in connection with this chapter : — 

Sternberg and Magnin, The Bacteria, 2d ed. — Fluegge, Fermente 
iind Mikroparasiten, in von Pettenkofer nnd Ziemssen's Handb. d. 
Hygiene, I Th., 2 Abth., 1 Hft. — Wernich, Desinfectionslehre zum prak- 
tisclien Gebrauch. — Tallin, Traite des Desinfectants etde la Desinfection. 
— Final Report of the Committee on Disinfectants of the American 
Public Health Association. — Sternberg, Disinfection and Personal 
Prophylaxis Lomb Prize Essay, 1886.] 



CHAPTER XXL 

Vital Statistics. 

The registration of vital statistics comprises the recording 
of the births, marriages, deaths, and diseases of a city. State, or 
nation. In no other way can a knowledge of the health of the 
inhabitants of such communities be obtained. For smaller, or 
special communities, such as armies, navies, schools, or special 
classes of workmen, the health status may be ascertained by 
direct methods; but for larger communities this is clearly 
impracticable, and the sanitarian is obliged to depend upon the 
census and the registration of births, marriages, and deaths. 

From a sanitary point of view, the most important object 
of a registration of vital statistics is to " give warning of the 
undue increase of disease or death presumed to be due to 
preventable causes, and also to indicate the localities in which 
sanitary effort is most desirable and most likely to be of use." ^ 

The duty of registration should devolve upon the sanitary 
administration. Local and State boards of health would seem 
to be the most appropriate media for collecting information bear- 
ing upon births, diseases, and deaths. It would seem also to 
be most appropriate to require the attending physicians to make 
reports of deaths and of cases of contagious diseases to the 
health authorities. 

REGISTRATION OF DEATHS. 

The data entered upon the record of death should com- 
prise the name, age, sex, color, nativity, descent, occupation, 
and civil condition of decedent, with date, place, and cause of 
death. Under the heading " Descent," the birthplace of each 
parent should be given. Occupation should be accurately 

ij. S. Billings, Registration of Vital Statistics, Am. Jour Med. Sciences, voL 
Ixxxv, p, 37. 

(359) 



360 TEXT-BOOK OF HYGIENE. 

specified. The place of death should indicate the exact locality 
(number of street) where it occurred. Both proximate and 
predisposing causes of death should be entered, and any com- 
plications which may have influenced the fatal termination 
should be noted on the record. 

This record should be in the possession of the local health 
authority before a permit for the burial of the deceased is 
granted. If this is not insisted upon, the report will soon be 
omitted and the registration become defective. 

REGISTRATION OF BIRTHS. 

The collection of data for an accurate registration of births 
is much more difficult than the record of deaths. Instead of 
requiring physicians and midwives in attendance at the confine- 
ment to report births, it would be more equitable and probably 
more effectual to compel the parents, under a penalty for failure, 
to record the birth of each child at the board of health. The 
items usually included in birth returns are : date and place of 
birth, sex and color of child, names of father and mother, 
parents' nativity and age, and father's occupation. Sometimes 
the residence of the mother, number of children previously 
borne by the same mother, whether the child is legitimate or 
not, and various other details are also added. It is evident that 
for sanitary purposes most of this information is entirely irrele- 
vant. It seems to the author that, for the purpose of the sani- 
tarian and medical statistician, the date and place of birth, sex 
and color of the child, and age, nativity, and occupation of 
both parents are sufficient. 

REGISTRATION OF MARRIAGES. 

The record of marriages is of no interest to the sanitarian. 
If, however, the registration could be made by a competent 
medical man, and the physical condition of the contracting par- 
ties noted, valuable deductions miglit be made in time, especially 
if the parties themselves and their offspring could be kept under 



VITAL STATISTICS. 361 

observation for many years. This, however, is so manifestly 
impracticable that it barely deserves notice in this place. 

REGISTRATION OF DISEASES. 

As has been seen in Chapter XIX, a large class of diseases 
are communicable from one individual to another, either 
directly, by contact, or mediately, by infection. In large com- 
munities it is therefore important that the sanitary authorities 
should possess information of the presence and prevalence of 
these diseases, in order that measures may be instituted for their 
restriction. It is true that in most cases the registration of 
deaths gives but too mournful evidence of the more fatal of the 
diseases of this class, but destructive epidemics could probably 
be frequently averted if preventive measures could be enforced 
early. Besides, in the case of dengue and epidemic influenza, 
the death-rate is so small that, if the registration of deaths were 
alone depended upon, no evidence whatever might be attain- 
able of the epidemic prevalence of such diseases. 

The registration of prevailing diseases is, therefore, one of 
the most important duties of the registrar of vital statistics. 
Prompt notice of all cases of infectious, miasmatic, or contagious 
diseases coming under tlieir professional notice should be required 
of all physicians. It is unquestionably just, however, that the 
physicians required to perform this duty should be properly com- 
pensated by the public, whose interests they serve. 

DEATH-RATE AND BIRTH-RATE. 

In order to calculate the annual death-rate of a place, two 
facts are required to be known : first, the actual or estimated 
population (generally obtained from the census), and, second, 
the number of persons who died within the district. The num- 
ber of deaths is then divided by the population, which gives the 
death-rate for each individual for the year. To find the death- 
rate per 1000, the death-rate as found above is multiplied by 
1000. Thus, the total number of deaths in the city of Baltimore 



362 TEXT-BOOK OF HYGIENE. 

during 1883 was 9380, and the estimated population 408,520. 

The death-rate for the year was 22.96 per 1000, obtained as 

follows : — 

9380 X 1000 

408,520 = 22.96 per M. 

To calculate the annual death-rate of a place for each 1000 
of the population from the returns for one week, the weekly 
population for the place is first ascertained, and then the total 
number of deaths for the week divided by the weekly popula- 
tion, and the quotient multiplied by 1000. The following con- 
crete example will render this clear : — 

The exact number of weeks in a year is 52.17747. The 
total population is divided by this figure, giving the weekly 
population. This gives for Baltimore, assuming the above esti- 
mate to be correct, a weekly population of 7829. For the week 
ending November 1, 1884, the deaths in that city numbered 148. 
The annual death-rate per 1000 — that is to say, the number of 
deaths in each 1000 of population, if the same ratio were main- 
tained throughout the year — is obtained as follows : — 

148X1000 ^^^ 

■ ^i-^K7i = 18.9 per M per annum. 

Out of the above 148 deaths, 32 were from infectious dis- 
eases. To find the annual death-rate per 1000 of population for 
this class of diseases, the same calculation is made, thus : — 

32 X 1000 , , 

HQOQ — = 4.1 per JM per annum. 

Or, if the percentage of deaths of infectious diseases be 
desired, the procedure would be as follows : — 

32 X 100 

TTo — - = 21.6 per cent, of the total deaths. 

Sixty-four of the decedents were under 5 years of age. 
The death-rate for this class is found in the same manner ; for 

example : — 

64X1000 ^^^ 

— 7099 — = 8.17 per M per annum. 

Or the percentage of these to the total deaths is found as in the 
last example. 



,1 

I 



VITAL STATISTICS. 363 

If it be desired to find the rate of infant mortality, i.e., the 
proportion of deaths among infants under 1 year of age to the 
total number of births for the same period, the following formula 
may be used. In the record just quoted the decedents under 
1 year of age numbered 37 ; the total number of births for the 
same week was 157. Hence — 

3TX 1000 _ ^^^ ,^ ^^^^ ^^^^ ^.^^^^^^ 

or nearly 1 to 4. 

Thirty-three of these 148 deaths were of colored persons. 
The death-rate of these to the total population is found in a 
similar manner to the above ; but if it is desired to ascertain the 
death-rate of the colored population alone, the weekly colored 
population must first be obtained and the rate calculated from 
this by the above formula. 

Birth-rates are found in a similar manner. The average 
age at death is ascertained by adding up the ages of all the 
decedents, and dividing the sum by the number of deaths. 

It will be evident, on a little thought, that there must be 
many sources of error in calculations based upon such uncertain 
data as are derived from the registration of births and deaths as 
conducted in most cities in this country. Besides, the subject of 
vital statistics is essentially abstruse, and requires no little readi- 
ness in mathematics to appreciate its profounder bearings. 
Hence, in the foregoing chapter no attempt has been made to 
penetrate beyond the immediate practical aspects of the ques- 
tions involved. 

[ To those desiring fuller information upon this subject, the 
following works are recommended : — 

Curtis, Vital Statistics, in Buck's Hj^giene and Public Health. — 
Billings, Registration of Vital Statistics, American Journal Medical Sci- 
ences, vol. Ixxxv. — Oldendorff, Morbilitaets and Mortalitsets-Statistik, in 
Realencyclopsedie d. ges. Heilk., Bd. IX. — Billings, Papers on Vital Sta- 
tistics, Sanitar}^ Engineer, vol. viii, ix. — Ibid., Cartwriglit Lectures on 
Vital and Medical Statistics, 1890.] 



CHAPTER XXII. 

Quarantine. 

(By Walter Wymax, M.D., Surgeon United States Marine-Hospital Service.) 

By quarantine is meant the adoption of restrictive measures 
to prevent the introduction of diseases from one country or 
locahty into another. The term itself conveys no definite idea, 
being derived through the Italian from the latin "quadraginta," 
meaning "forty" and implying forty days, the period of deten- 
tion imposed on vessels by the first quarantines established at 
Venice in 1403. The old significance of the term is entirely 
lost in its present application, which is quite general. Thus, 
besides regular maritime quarantine, mention is often made of 
land, railroad, cattle, shot-gun, house, and even room quaran- 
tines. 

The name of a disease or article of merchandise may be 
ased in prefix, as in "yellow-fever quarantine," small-pox, 
cholera, or rag quarantine. Moreover, quarantines are described 
as properly beginning at the port of departure, and as quaran- 
tines of inspection only, the fumigation and detention being 
imposed at some neighboring station. The term, therefore, is 
applied not only to establishments, but indifierently to persons, 
animals, diseases, localities, and measures. 

There is need of a clear understanding with regard to the 
term, for when, as occasionally, quarantine is ridiculed, or the 
assertion is made that the English disbelieve in quarantine, a 
wrong impression will be received, unless it is understood that 
only particular and obsolete forms of quarantine are meant, 
and not quarantine in the broad sense just mentioned. 

The subject admits of two natural divisions — maritime and 
land quarantine ; but before describing them attention is called 
to the following table, containing a list of diseases that are ordi- 
narily found in official quarantine proclamations : — 

(365) 



366 TEXT-BOOK OF HYGIENE. 

QuARANTiNABLE Diseases. — Table XXIX. 



Disease. 


Period of Incubation, in Days. 


Shortest. 


Longest. 


Usual. 


Authority and Remarks. 


Plague 

Yellow fever . . . 

Cholera 

Tj'phus fever . , . 
Small-pox .... 

Measles 

Diphtheria. . . . 
Typhoid fever . . 
Scarlet fever . . . 
Relapsing fever . . 

Dengue 

Leprosy 


1 

2 
1 
5 
7 
2 
7 
1 
5 
1 


*9 
14 
21 
20 
14 
10 
28 
weeks. 
7 
10 


2 to 4 
5 to 14 

10 

10 

2 to 5 

21 
4 to 7 

6 

5 


Bristow. Undetermined. 

Da Costa, Bartholow. 

Bartholow. 

Bristow. 

Da Costa. 

Da Costa. 

Bartholow. 

Bartholow. 

Da Costa. 

Bartholow. 

Bartholow. 

Undetermined. 



The above list illustrates the growth of the sanitary idea 
and belief in quarantine. For many years, as now at some 
ports, the list was limited to yellow fever, typhus, cholera, and 
small-pox. It was thus limited at Boston prior to 1881, since 
which date diphtheria, scarlet fever, typhoid fever, and measles 
have been added. The statutes of New York define as quaran- 
tinable "yellow fever, measles, cholera, typhus or ship fever, 
small-pox, scarlatina, diphtheria, relapsing fever, and any dis- 
ease of a contagious, infectious, or pestilential character, which 
shall be considered by the health officer dangerous to the public 
health." 

At Gibraltar, the English sanitary authorities include 
dengue and epidemic rose-rash among the diseases subject to 
their quarantine regulations. 

The most recent addition to the list in this country is 
leprosy, to prevent the introduction of which, and in accord- 
ance with a resolution of the American Public Health Associa- 
tion, a prohibitory circular was issued by the Surgeon-General 
of the Marine-Hospital Service, December 23, 1889. 

Other diseases which may properly call for quarantine are 
mumps, whooping-cough, chicken-pox, epidemic dysentery, 



MARITIME QUARANTINE. 3G7 

glanders, tetanus, beriberi, epidemic influenza, and pulmonary 
tuberculosis. 

Influenza may be considered quarantinable imder certain 
circumstances, a successful quarantine being reported by Dr. 
Trudeau, whose cottage sanitarium, in the Adirondacks, New 
York, w^as thus kept exempt during the epidemic of 1890. 

With regard to pulmonary tuberculosis the ground is taken 
by the writer that this disease, at least among immigrants, should 
be excluded from the United States by quarantine. 

MARITIME QUARANTINE. 

In describing a maritime quarantine it should be borne in 
mind that the details in the plant must vary in accordance with 
the special demands of eacli port. 

Thus, it is not to be expected that at Charleston, where 
immigration is limited, there should be the same provisions for 
detention of immigrants as ^ at New York, through whose 
portals more than one-third of a million of immigrants pass 
each year ; or San Francisco, wdiere enter the throng of travelers 
and immigrants from the far East. 

We should not expect that Boston, in the more salubrious 
North, would have the means or adopt the practice of emptying, 
cleaning, and fumigating every vessel from an infected port, 
which process has proven to be the sine qua non of exemption 
to the State of Louisiana. 

Nor should we expect Pensacola, with a completely- 
equipped national refuge-station near at hand (at Chandeleur 
Island), to erect an expensive disinfecting-house, with modern 
steam disinfecting-chambers, as has been recently done for the 
port of Galveston by the health authorities of Texas. 

But, leaving these variations for subsequent notice, the 
first thing to be considered in the establishment of a complete 
maritime quarantine is proper location. This must be at a 
point remote from city or village boundaries, and not likely to 
be encroached upon by urban growth. It should be more or 



368 TEXT-BOOK OF HYGIENE. 

less removed from the channels of commerce, and yet be easily 
accessible. Indifference to proper location could readily make 
the quarantine a source of danger instead of a protection. After 
proper location, the main requirements may be stated as 
follows : — 

1. A boarding-station. This includes a boat-house with 
boatmen's quarters, so located as to avoid possible infection from 
the lazaretto and to be within easy reach of passing commerce. 

2. A boarding-boat, prefera,bly a steamer. 

3. An anchorage. The ancliorage is the place of detention 
of the infected vessel. It should be conveniently removed from 
the main establishment and safely remote from the track of 
commerce. Its position should be sheltered, and good holding- 
ground for vessels' anchors is of the first importance. The 
channel to the anchorage, and, if necessary, its boundaries, 
should be plainly marked by buoys. 

4. A fumigation steamer, to be described under " Quaran- 
tine Contrivances." 

5. A wharf. The wharf should be in water of at least 20 
feet depth, and there should be constructed upon it a ware- 
house, tanks for holding disinfecting-solutions, and a disinfection- 
house containing steam disinfecting-chambers. 

6. A lazaretto or hospital for treatment of contagious 
diseases. 

7. A hospital for treatment of non-contagious diseases. 

8. Barracks for the detention in groups of " suspects," or 
persons who have been exposed to contagion or infection. 

9. Quarters for medical officers. 
10. A cremation-furnace. 

No better understanding of the subject can be had than by 
a brief survey of the several varieties of maritime quarantines 
that are now maintained on the coasts of the United States. 
First should be mentioned the national quarantine stations, eight 
in number, established at points of danger where either local 
quarantine is defective, or where, by reason of peculiar advan- 



MARITIME QUARANTINE. 369 

tage in location, protection is afforded to several States by one 
station. These stations are as follow: — 

Delaware Breakwater Quarantine Station, Lewes. Del.; 
Cape Charles Quarantine Station, Fisherman's Island. Va. ; 
South Atlantic Quarantine Station, Blackboard Island, Sapelo 
Sound, Georgia; Key West Quarantine Station, Tortugas 
Islands, Fla. ; Gulf Quarantine Station. Chandeleur Island, 
Miss.; San Diego Quarantine Station. San Diego, California; 
San Francisco Quarantine Station, Angel Island, San Francisco 
Bay, California; and Port Townsend Quarantine Station, Port 
Townsend, ^Yashington. 

Most of these stations will be complete in plant and equip- 
ment within a short time, but pending completion active quaran- 
tine is maintained the whole year through at all of them, San 
Francisco excepted. — there being a local quarantine at this port. 

The estimated cost of the national quarantine station at 
Angel Island, San Francisco Bay, is $175,000, exclusive of the 
site, which was in previous possession of the government. 

Surgeon-General Hamilton, in a recent report, says: — 

" It is evident that a few complete stations of this kind 
will take the place of the many municipal quarantines. The 
latter will become, e^'entually. simply boarding-stations, and 
vessels requiring treatment will be sent to the nearest govern- 
ment quarantine station." 

Xo fees are exacted at the national stations. 

Many of the local quarantine establishments, while entirely 
effective for ordinary quarantine, the occasional detection and care 
of a few contagious cases, would prove insufficient and become, 
in fact, more dangerous than beneficial in the presence of a heavy 
mroad of an epidemic disease, such as the appearance of a ship 
with a thousand emigrants aboard, having a history of many 
deaths at sea from cholera, and cholera still prevailing among 
them. Deficiencies in the plant and the want of modern appli- 
ances and proper accommodations woidd create embarrassment, 
while the location, once remote from populous centres, but now 

24 



370 TEXT-BOOK OF HYGIENE. 

no longer isolated, would at once be recognized as hazarding the 
safety of the neighboring population. 

It is in recognition of these facts that the health authorities 
of the various States and cities interested have contributed their 
influence to the establishment of the national quarantines, using 
them as refuge-stations. 

Among the State and local quarantines, variety of type is 
presented by those of Boston, New York, Louisiana, Galveston, 
Philadelphia, Baltimore, and Charleston. The first four of 
these are complete in themselves, and independent of extraneous 
aid. The others make use of the national stations, particularly 
for the anchorage and cleansing of foul ships. The city of 
Charleston, for example, has a complete plant of approved 
modern design for the disinfection by steam of clothing, baggage, 
and bedding, but use is made of the neighboring national station 
at Blackboard Island for the treatment of the infected vessel. 

To complete this description of maritime quarantines it 
only remains to mention the special characteristics of the State 
quarantine establishments of New York and Louisiana. 

THE NEW YORK QUARANTINE. 

This consists of — 

1. A ship, or hull, anchored in the lower bay, — the bay 
farthest from the city. The hull is anchored about 4 miles 
inside of Sandy Hook, and about 11 miles from New York. 
This is the boarding-station from May until November, vessels 
being visited by means of a row-boat. 

2. Swinburne Island, — called also Dix Island, — located 
two or three miles from the boarding-station, nearer to New 
York, with an area of two or three acres, on which are erected 
the hospitals for the treatment of the sick, and also a cremation- 
furnace. 

3. Hoffman Island, — like the former, an artificial island, — 
still nearer to New York by about one mile, on which are build- 
ings for the accommodation of two thousand immigrants, with 



THE LOUISIANA QUARANTINE. 371 

interior arrangements for their division into groups, while await- 
ing the development of any contagious or infectious disease 
among them. A steam disinfecting-apparatus for the dry or 
moist heat disinfection of baggage, clothing, etc., has been 
established upon this island. 

4. Residence of the health officer, on the "Narrows," near 
Clifton, Staten Island, 6 miles from New York. 

5. The Anchorage, where infected vessels are treated. This 
is also in the lower bay, which is of so great area that a safe 
location of the vessel is easily effected. 

THE LOUISIANA QUARANTINE. 

To the Louisiana State Board of Health and its successive 
presidents, Drs. C. B. White, Samuel Choppin, Joseph Jones, 
Joseph Holt, and C. P. Wilkinson, is due the credit both of 
combating the pernicious theory of non-quarantine and of per- 
fecting a system of quarantine that is recognized as the most 
extensive and efficient ever devised, and from which a number 
of others have been modeled. Though utilizing the devices of 
others, notably that of Quarantine Officer Dr. Perry, for gener- 
ating and forcing into vessels' holds sulphur dioxide, and 
though his plant has been improved by his successor, neverthe- 
less the credit of this new and thorough system is justly given 
to Dr. Joseph Holt, President of the Board of Health from 1884 
to 1888, to whose determined energy and genius sanitary and 
commercial interests are equally indebted. 

The improved quarantine consists of, first — 

The Mississippi Biver Quarantine Station. This is located 
about 90 miles below New Orleans and 4 miles above the " Head 
of the Passes," or point where the river divides into its three 
main outlets. 

The plant consists of five buildings exclusive of out-houses, 
viz., a disinfecting-shed and boiler-room, quarters and mess-hall 
for the disinfecting-crew, boat-house and boatmen's quarters, and 
two residences for the quarantine officer and his assistant. 



372 TEXT-BOOK OF HYGIENE. 

The disinfecting-shed immediately adjoins a wharf built in 
water of sufficient depth to allow the largest vessels to be 
, moored alongside. 

The following description is from the report of Dr. C. P. 
Wilkinson, President of the Louisiana State Board of Health : — 

The disinfecting apparatus consists of three cylindrical steel cham- 
bers and appurtenances, each cylinder being 50 feet long and 8 feet in 
diameter. The ends are spherical, and that facing the river or front end 
is movable, swinging open by means of a crane. At a point 50 feet in 
front of each cylinder commences a double, iron, elevated track, which, by 
a movable section, continues into and throughout the length of each 
cylinder. 

On this track rolls a truck 48 feet in length, and from this truck 
are suspended thirty clothes-racks of 5 bars each. The interior of each 
cylinder contains an arrangement for the emploj^ment of moist and dr}^ 
heat, separately and together. The necessar}^ heat is supplied by a 
40-horse-power steam-boiler at 85 to 100 pounds' pressure. 

Surmounting the shed is a cypress cistern, the bottom of which is 
41 feet above the river-surface, capable of holding 7000 gallons of fluid. 
In this cistern is stored a solution of mercuric chloride, 1 part to 1000 
of water by weight. Pipes lead from this cistern to the outer edge of 
the wharf, and at that point have rubber-hose attachments of suflScient 
length to lead to all parts of a very large vessel, and the hoses terminate 
in hard-rubber roses of 6-inch face. 

The fumigating apparatus, heretofore on a tug, but now proposed 
to be erected on rail-cars on the wharf, consists of a reverberatory sul- 
phur-furnace, with 250 feet of galvanized-iron conductors, 12 inches in 
diameter, and a steam fan. The furnace, 24 inches wide, 48 high, and 40 
deep, is provided with four cast-iron pans, 30 inches long, 23 wide, and 4 
deep, each pan having over 1^ cubic feet capacity, or about 175 pounds 
of sulphur. The pans are set on split brick, and are so placed that the 
current of air driven by the fan into the bottom passes over each pan of 
burning sulphur alternately, out through the top and along the conduc- 
tors down into the holds of vessels. 

The process of disinfection of vessels consists in placing all baggage, 
bedding, curtains, carpets, linen, etc., — in fact, all textile fabrics of vessel, 
crew, and passengers, — on the suspended clothes-racks, which are then 
drawn into the C3dinders by a windlass, and applying dry heat until the 
thermometers mark 185° F. (85° C.),at which point moist heat is turned 
on, the temperature rapidly rises to 215° to 220° F. (102° to 105° C.),and 



THE LOUISIANA QUARANTINE. 373 

the gauges usnall}^ record a pressure of T pounds to the square inch, at 
which point the blow-off valves open, preventing any danger of explosion. 
The contents of the chambers are kept at this temperature and pressure 
for thirty- minutes, the cj'linders are then opened, and the goods turned 
over to their owners. The vessel in the meantime is washed down — cabins, 
forecastles, decks, and holds — with the mercuric-chloride solution, and 
fumigated by means of the furnace and fan. In the case of loaded vessels, 
washing the interior is omitted, on account of danger to cargo. The holds 
are, however, thoroughly fumigated, and, by a special arrangement of 
" cargo wells," the gas penetrates every interspace of cargo. These wells 
are constructed at port of departure, and consist of a long wooden box 
about two feet across, and reach from the bottom to top of holds, the cargo 
being stowed around them at loading-point. The conductor from the 
sulphur-furnace is led into the well, the hatches are tightly closed, and, 
under pressure, the fumes of sulphur are driven into the vessel, the gas 
passing around every package envelope, no matter how tightly packed, 
and chemical examination showed that in the case of sugar-bags it pene- 
trated to the depth of three-fourths of an inch. The character of 
cargoes arriving here from infected ports is almost exclusively coffee and 
sugar, the former always, and the latter nearly always, in bags, neither 
offering obstacles to good and sufficient fumigation in situ. 

When necessary, the cargo is shifted to lighters for more thorough 
disinfection. 

Passengers are required to don their disinfected wearing-apparel to 
permit disinfection of that they may be wearing on arrival. 

Most all of the quarantine work is accomplished at this 
Mississippi Kiver Station. 

The second or Lower Quarantine Station is situated in 
Pass a L'Outre, an unused outlet of the Mississippi, a few miles 
beloAv the Head of the Passes. At this station is the lazaretto, 
or hospital for infectious diseases, and it is the anchorage also for 
infected vessels. 

Other stations are the Advance Guard Inspection Station 
at Port Eads, 110 miles below New Orleans, where the waters 
of South Pass are jettied into the Gulf, and the Pigolets and 
Atchafalaya Stations. The two latter control the two lateral 
approaches to New Orleans, and, as the shipping coming through 
these two channels is light in tonnage and mostly from domestic 



374 TEXT-BOOK OF HYGIENE. 

ports, by imposing a quarantine of forty days' detention the two 
approaches are practically closed, compelling all vessels to seek 
the Mississippi as the only available route to New Orleans. 

The following description is for the most part verbatim, 
from the pen of Dr. Joseph Holt (see " Transactions of the 
American Public Health Association," 1887, vol. xiii) : — 

When an inward-bound vessel comes into the offing, she is imme- 
diately boarded by a thoroughly skilled medical officer, and a careful in- 
spection is made of her sanitary record and present condition. If from 
a non-quarantined port, and all is well, she is given pratique and goes on 
to the city. If from a quarantined port, but presenting a clean health- 
record of voyage and no evidence of sickness of a dangerous or doubtful 
character, she proceeds to the Mississippi River Quarantine Station, 
where she is subjected to a full course of sanitary treatment, and is de- 
tained such length of time, not exceeding five days (except in rare in- 
stances wherein further observation may be deemed necessary), as the 
Board of Health may provide. 

If, upon inspection of a vessel entering the river she is found to be 
foul, — that is, showing positive or suspicious evidence of infection either 
in a person then ill or in a foul health-record of voyage, — she is at once 
remanded to the lower station in Pass a L 'Outre. The sick, if any, are at 
once removed to the hospital, where every provision has been made. The 
vessel with the well on board is dropped down-stream a few hundred 
yards and anchored. The quarantine tug-boat, with its complete dis- 
infecting outfit, comes alongside, and the work of disinfection begins, 
and does not cease until the vessel has been subjected to the most vigor- 
ous application of the solution of bichloride of mercury, her atmosphere 
below deck completel}^ replaced with one heavil}^ charged with sulphurous 
oxide, and every article of baggage and ship's wardrobe has been satu- 
rated with the mercuric solution. 

A ship known to be infected with one of the three great pestilential 
diseases — small-pox, cholera, or yellow fever — can stand and must endure 
extraordinary treatment, even if clothing is wetted and some articles 
damaged. 

The immediate segregation of the sick and the well and disinfection 
of the ship and all baggage (in the case of a cholera-infected vessel, 
extended to the disinfectant washing out and refilling of the water-tanks, 
destruction of the food-supply, and revictualing the vessel) constitute 
the treatment of an infected vessel at this station. The ship, together 
with all on board, is held for observation a period of ten da3^s or more, 



THE LOUISIANA QUARANTINE. 375 

according to circumstances, when she is released and proceeds to the 
Mississippi River Station, where the processes of sanitary treatment are 
repeated, with the addition of the use of moist heat applied to baggage, 
ship's apparel, etc. ; and the vessel is then allowed to proceed to the 
city. 

The tug-boat mentioned is of sufficient power to move a vessel to 
or from the wharf, and is equipped with a complete outfit for generating 
and appl3^ing germicidal gas for the displacement of the entire atmos- 
phere within the ship, transported, perhaps, directly from some infected 
port. In the hold of this tug is constructed a wooden tank of 2000 
gallons capacity, to hold the bichloride-of-mercury solution, for treatment 
of vessels in the lower quarantine. This tank is furnished with a steam- 
pump made of iron (on account of the greater resistance of that metal 
to amalgamation), supplied with a |-inch rubber hose. 

The quarantine procedure at the Louisiana quarantine 
stations may be further understood through the following quar- 
antine proclamation by the Governor of the State, May 1, 

1890 :— 

Executive Department, State of Louisiana. 

In conformity with the provisions of Section 3049 of the Revised 
Statutes of the State, and upon the advice of the State Board of Health, 
requesting the Governor to issue his annual proclamation of quarantine 
against the hereinafter enumerated and mentioned ports, to take effect 
from and after the 1st day of Ma}^, A.D. 1890, to wit : — 

All vessels arriving at the several quarantine stations in this State, 
together with their crews, cargoes, and passengers, shall be subjected to 
inspection by the quarantine officers at said stations. 

All vessels, together with their cargoes, crews, passengers, and 
baggage arriving at the Mississippi River Quarantine Station from inter- 
tropical American and West Indian ports shall be subjected to thorough 
maritime sanitation according to the following schedule, to wit : — 

First Class. — Vessels arriving from non-infected ports. 

Second Glass. — Vessels arriving from suspected ports. 

Third Glass. — Vessels arriving from ports known to be infected. 

Fourth Glass. — Vessels which, without regard to port of departure, 
are infected ; that is to sa}^, vessels which have yellow fever, cholera, or 
other contagious or infectious disease on board at time of arrival, or 
have had same on voyage. 

Vessels of the first class to be subjected to necessary maritime 
sanitation at the Mississippi River Quarantine Station, without detention 



376 TEXT-BOOK OF HYGIENE. 

of either vessel or persons longer than may be necessary to place such 
vessel in perfect sanitary condition. 

Vessels engaged in the tropical-fruit trade and coming from known 
non-infected localities, and whose sanitar}^ condition and health-record 
are satisfactor}", may be allowed to pass the quarantine station after 
inspection, subject, however, to such regulations and sanitary treatment 
as the Board of Health may prescribe. 

Vessels of the second and third classes to undergo the same con- 
ditions as those of the first class, together with detention for observation 
for a period of five full daj^s from hour of arrival in quarantine. 

Vessels of the fourth class to be remanded to the Lower Quarantine 
Station, there to undergo sanitation and detention of vessel and persons 
such length of time as the Board of Health ma}^ determine. 

All vessels arriving from ports known or suspected to be infected 
with cholera or small-pox, or which ma}^ hereafter become infected, shall 
be subjected to maritime sanitation and such detention as the Board of 
Health maj" determine. 

Vessels arriving from the above-named ports and places, and be- 
longing to the second, third, and fourth classes, as is set forth in the 
above schedule, shall not be allowed to pass the Rigolets, the Atchafalaya, 
or Lake Charles Quarantine Stations, or other State quarantine stations 
which may hereafter be established, without having undergone a period 
of detention of forty daj^s and thorough cleaning and disinfection. 

Now, therefore, I, Francis T. Nicholls, Governor of the State of 
Louisiana, have thought proper to issue this, my annual proclamation 
of quarantine, directing that quarantine shall take eifect from and after 
Thursday, the 1st da}^ of Maj^, A.D. 1890, against the above-mentioned 
ports, and as contained in the foregoing schedule. 

Quarantine officers at the several stations in this State are especially 
charged and required to strictl}^ enforce the execution of this proclama- 
tion, and the Board of Health in the cit}' of New Orleans is requested to 
prosecute vigorously all violations of the same, as well as the quarantine 
laws and regulations of this State. 

In testimony whereof I have hereunto affixed my signature, authen- 
ticated with the seal of the State of Louisiana, at the city of Baton 
Rouge, this eighteenth da^- of April, in the 3^ear of our Lord one thou- 
sand eight hundred and ninety. 

Francis T. Nicholls, 

Governor of Louisiana. 
By the Governor : 

Geo. Spencer, 

Assistant Secretary of State. 



QUARANTINE CONTRIVANCES. 377 

Special Svggestiojis to Oivnei^s, Agents^ Masters of Vessels, and Passengers. 

The Louisiana State Board of Health recommends the folloT^Mng 
suggestions to agents, owners, masters of vessels, and passengers for 
the purpose of facilitating the work of quarantine oflicers and reducing 
the period of detention to a minimum : — 

1. That vessels should be stripped during the quarantine season 
of all woolen hangings, carpets, curtains, and such-like materials, and 
upholstered furniture as far as practicable. Hair or moss mattresses to 
be replaced b}' wire or wicker beds. 

2. That as far as possible vessels trading with tropical ports should 
be manned with acclimated crews. 

3. Masters of vessels and ship and consular agents are earnestly 
requested to instruct passengers from quarantinable ports to dispense, as 
far as possible, with baggage wliicli may be injured bv wetting, in case 
of pestilential outbreak on board, wliile undergoing disinfection. Such 
passengers are especialh' warned against bringing silks, laces, velvets, 
and other fabrics of delicate texture, as they will be compelled to assume 
all risks of injury. 

4. While in ports infected with yellow fever, vessels should be 
anchored out in the harbor, when this is possible, and the crew prohibited 
from going ashore, especially at night. 

5. When practicable, cargoes should be loaded in such a manner as 
to allow access to the pumps, and also to enable the quarantine officials 
to pump out and wash the bilge. 

6. Special attention should be given to cleanliness of vessels and 
persons, and provision should be made for all possible ventilation of 
the entire vessel. The best disinfectants and instructions for using the 
same can be obtained by application to the Board of Health or any of 
its officers. 

7. Masters should, before arrival, see that the bilge is thoroughly 
pumped out and cleansed, and that the entire vessel be put in such good 
sanitar}^ condition as to permit of the least possible detention. Fruit 
vessels, particularh', should be kept thoroughly cleansed for the purpose 
of avoiding dela}^ at the quarantine station. 

8. Vessels observing the above recommendations will receive special 
consideration at the quarantine station, detention and cost of cleaning, 
disinfecting, etc., being materially lessened thereby. 

QUARANTINE CONTRIYANCES. 

Of modern contrivances iirst should be mentioned the 
disinfection steamer. This must be a powerful boat on the 



378 TEXT-BOOK OF HYGIENE. 

general plan of a tug-boat, about 85 feet in length on the II 
water-line, provided with iron tanks of at least 2000 gallons' 
capacity for holding the solution of bichloride of mercury, to 
which may be attached a steam-pump and rubber-outlet hose. 
To preyent contact of the mercury with the iron the tanks may 
be painted with three coats of red lead and two of paraffine paint 
(Holt). 

The steamer is also provided with a steam-fan, by means of 
which fresh air may be made to displace foul air in the hold of 
the vessel under treatment. A sulphur-furnace is also provided 
for the generation of sulphur dioxide, which is conveyed into 
the hold of the adjoining ship after displacement of the foul air. 

The improved pattern of sulphur-furnace is the design 
of Assistant-Surgeon Kinyoun, Marine-Hospital Service, who 
states that it is on the principle of a reverberatory furnace, con- 
sisting of a series of shelves arranged one above another, each 
shelf holding a pan of burning sulphur. A forced draught is 
kept up by means of a fan-blower connected at the bottom. 
The draught of air charged from the burning sulphur of each 
shelf is made to reach and pass over the shelf above by means 
of apertures made by shortening the shelves alternately at their 
rear and front extremities. "With an experimental furnace Dr. 
Kinyoun states that "repeated experiments gave from 14 to 16 
per cent, of SO2, temperature 21° C, while burning sulphur in 
a closed place gave only 6 per cent, at 21° C, i.e., it would not 
support the combustion of sulphur above that percentage.^ 

The furnace belonging to the fumigation vessel of the 
Louisiana Board of Health is of a special pattern. Dr. 
Salomon, secretary of the board, states that for each vessel 200 
to 800 pounds of sulphur will be used, according to the size of 
the vessel, and the fumes will be allowed to remain in the hold, 
with hatches sealed, twenty-four to thirty-six hours, or longer.^ 

* See Abstracts of Sanitary Reports, Marine-Hospital Service, vol. iii. pages 3-17 and 348. 

^ See Transactions of the American Pnblic Health Association, vol. xiii, for Dr. Holt's 
description of his system, and vol. xiv, page 113, for Dr. Salomon's reports and improvements 
thereon. 



STEAM DISINFECTING-CH AMBERS. 379 

The amount of sulphur used at the New York Quarantine 
by the pot method (pots of burning sulphur lowered mto the 
hold) is 50 to 100 pounds, according to the vessel's size).^ 

At Pensacola about 12 pounds of sulphur are used to every 
100 tons' register, and the fumigation lasts twelve hours. 

At the Delaware Breakwater 4 pounds are used to each 
1000 cubic feet of space, and the fumes are kept twenty-four 
hours in the vessel's hold. At Chandeleur, 35 pounds in hold 
to 100 tons. 

STEAM DISINFECTING-CHAMBERS. 

The principle of disinfection by steam was first advocated 
by Dr. A. N. Bell, of Brooklyn, but the contrivance about to be 
described was first used by Dr. Joseph Holt, and improved by 
Dr. Wilkinson and others. These chambers, two or three at 
one station, consist of jacketed, cylindrical shells, made of strong 
boiler-iron, each shell being 40 or 50 feet long and 7 or 8 feet in 
diameter, inside measurement, furnished with doors at each end.^ 

The jacketing is for the purpose of using the chambers 
with either dry heat or with superheated steam. 

Articles of clothing, bedding, etc., are arranged on trucks, 
which are run into the chamber at one end and taken out at 
the other. A bacteriological test made by Dr. Kinyoun at the 
Louisiana Quarantine Station showed that all germs were killed 
after exposure to a dry heat of 79.4° C, obtained in sixteen 
minutes, steam then being turned on for twenty minutes.^ 

Another and simple contrivance for fumigating is the 
" Liquid Sulphurous Dioxide," the compressed gas furnished in 
metal reservoirs, which, being opened, the gas rapidly escapes. 
By this means any proportion of SO 2 can be introduced in a 
vessel without any apparatus. It is manufactured in Hagenau 
and in Oberhausen, Germany, and may be purchased in New 

"•See Report by Dr. John H. Rauch upon an Inspection of the Atlantic and Gulf Quar- 
antines. State Printer, Springfield, 111., 1886. 

^ See description under " liouisiana Quarantine." 

' For plans and specifications, see Annual Report Marine-Hospital Service for 1889, and 
Abstract of Sanitary Reports, vol. iv, page 443. For Dr. Kinyoun's experiments, see Abstract 
Sanitary Reports, vol. iii, pages 117 to 147. 



380 TEXT-BOOK OF HYGIENE. 

York, and of Finlay & Brunswig, wholesale druggists, New 
Orleans, at a cost of five cents per pound when not less than 
one ton is taken. It has been suggested that this may take the 
place of the sulphur- furnace and appliances on the steamer. 
The cost by this method is thought to be but little, if at all, 
greater than by the furnace method, if the interest on the plant 
is added to the latter. This method has been occasionally used 
at the Grosse Isle Quarantine, in Canada, but to establish its 
complete practicability will require further test. 

ADMINISTRATION OF MARITIME QUARANTINE. 

The following are the rules and regulations of — 

1. The National Quarantine Stations. 

2. State Quarantine Service of Texas. 

3. The Local Quarantine at Pensacola, Florida. 
In these three types will be found all the ordinary admin-1 

istrative regulations, which are, however, subject to minor] 
changes yearly. 

1. Regulations for the National Quarantine Stations. 

(From the Regulations of the Marine-Hospital Service, 1889. ) 

328. At ports where quarantine may be established by special statute 
or by the Secretaiy of the Treasury, eveiy v^essel, before being permitted 
to enter, shall present to the Collector of Customs satisfactory evidence 
either that said vessel had not, at any time during a period of thirty 
days immediatelj^ preceding its arrival, touched at or communicated 
with any foreign port where cholera or yellow fever exists, or small-pox 
was known to exist in an epidemic form ; that there had not been at any 
time during that period any case of contagious disease on board ; and 
that said vessel does not convey any person or persons, merchandise, or 
animals affected with any infectious or contagious disease, or that the 
said vessel has been thoroughly cleaned and disinfected by the quarantine 
officer, and is free from infection at the time of entry. The certificate to 
that effect, of the medical officer of the Marine-Hospital Service, acting 
as quarantine officer for the United States at the port, shall be accepted 
by the Collector of Customs as satisfactor}^ evidence, and the medicalg 
officer shall, before granting such certificate, satisf^^ himself that the, 
matters and things therein stated are true. 

329. Vessels coming from a foreign port or countr^^ where cholera 



i 



ADMINISTRATION OF MARITIME QUARANTINE. 381 

or yellow fever exists, or small-pox is known to have existed in an epi- 
demic form within thirty days preceding their arrival, and vessels or 
vehicles conveying any person or persons, merchandise, or animals 
affected with an}' contagious disease, or having had on board at an}^ time 
during the thirt}' da^'s preceding their arrival any case of contagious 
disease, shall not enter an}- port of the United States until such disin- 
fection or other precautionary measures shall liave been performed as 
prescribed by these regulations, and the certificate of the medical officer 
of the Marine-Hospital Service, or other designated agent of the Treasury 
Department, shall, in such cases, as in the cases referred to in the pre- 
ceding paragraph, be accepted by the Collector of Customs as satisfactory^ 
evidence of compliance with the regulations. 

330. Quarantine stations will be governed b}' the general regulations 
of the Service, so far as applicable. 

331. Xo pilot or other person will be allowed to leave a vessel until 
the vessel shall have been inspected b}' the quarantine officer, and any 
person violating this regulation shall be reported to the nearest United 
States attorne}' for prosecution under the act of August, 1888, and no 
person will be allowed to leave the quarantine reservation, or a vessel 
placed in quarantine, without permission of the quarantine officer. 

332. Quarantine officers are hereb}' empowered and authorized to 
cause the temporary arrest of an}' person violating the quarantine regu- 
lations, and turn them over to the custody of the nearest United States 
marshal, and notify the United States attorney to that effect ; or, if that 
be impracticable, to confine them on the quarantine reservation, subject 
to the orders of the said marshal or attorney. 

333. When a vessel arrives at a United States quarantine boarding- 
station, the inspecting officer will examine the papers of the vessel to 
inform himself of her passengers and cargo; he will require all persons 
named on the passenger-list and crew-list to present themselves and 
answer to their names at muster. Should any person have died on the 
voyage, the circumstances of the death will be inquired into, and, in case 
of there being any person sick, such person will be carefully examined 
by the inspecting oflficer, the only exception being, in case of naval 
vessels, the statement of the senior surgeon or medical officer as to the 
sanitary condition of the vessel will be accepted. 

334. "When persons are found sick of cholera, small-pox, yellow 
fever, plague, or diphtheria, they shall be immediately removed to the 
quarantine hospital, and the vessel be thoroughly disinfected. 

335. In order to stimulate ship-masters to aid in securing a clean 
ocean-going fleet, the following regulations concerning the treatment of 
foul ships will be observed at all national quarantine stations : — 



382 TEXT-BOOK OF HYGIENE. 

When a vessel arrives at any national quarantine station from an Infected port, and 
requires disinfection, she will be subjected to ordinary disinfection, as provided in former 
regulations. 

When any vessel shall arrive at a national quarantine station in such foul condition 
as to render her dangerous from a sanitary point of view, and is found to require cleansing 
and disinfection, having at any former time within one year been subjected to ordinary 
disinfection, such vessel will be required to undergo extraordinary disinfection, which, in 
addition to the ordinary measures, will include holy-stoning, scraping, the taking out of 
rotten wood, a second disinfection, and interior repainting, all of which will be required 
before granting a certificate of free pratique. 

336. The recognized method of disinfection of vessels will be, for 
all vessels: a, by bichloride of mercur}^ ; 6, by sulphurous oxide; c, by 
flushing with sea-water. 

33T. For disinfection of clothing and other fomites, dry heat will 
be used whenever practicable, and when it is not practicable to use dry 
heat the sulphurous-oxide fumigation will be used. 

338. The Supervising Surgeon-General will from time to time issue 
detailed instructions for the practice of disinfection, under these regula- 
tions, which instructions will include such improvements as may be 
suggested by the advance of science. 

2. Quarantine Regulations, State op Texas. 
General Rules. 

No. 1. After the declaration of quarantine by the Governor, every 
vessel, before entering any port on the coast of Texas, shall be boarded 
by quarantine officers, and the crew and passengers be subjected to such 
questions by said officers as will be necessary to determine their probable 
connection with epidemic influence or infectious diseases. 

No. 2. Yessels hailing from infected districts, or having communi- 
cated with others from such districts, by contact or otherwise, shall be 
placed in quarantine, casting anchor at such place or places as may be 
designated by quarantine officer of port, and a complete list of both crew 
and passengers taken. Notice in writing shall be given captains, holding 
them responsible for strict non-communication of both passengers and 
crew with other vessels or with any one from shore. Violation of this 
rule shall be punished by fine against vessel and captain, not less than 
$500 or more than $1000. 

No. 3. From the masts of all vessels in quarantine shall be displayed 
a yellow flag, of such dimensions as to warn off others approaching. 

No. 4. All vessels held in quarantine shall be under the direction 
of port quarantine officer, and put in thorough sanitar}^ condition by fumi- 
gation of hold, washing decks with disinfecting fluids, and purifying 
bilges, etc. 



ADMINISTRATION OF MARITIME QUARANTINE. 383 

No. 5. Costs of fumigation, disinfection, etc., shall be at expense of 
vessels. 

Xo. 6. A complete muster of crew and passengers must again be 
taken before vessels are given free pratique^ and a concise report made 
to State health officer. No vessel shall be finall}^ released without per- 
mission of State health officer. 

No. 7. Families of quarantine officers will not be allowed at stations 
without special permission from State health officer during the existence 

of quarantine. 

Pilots. 

Pilots will not be allowed to visit, or board, or communicate with 
anv vessels without permission of port quarantine officer, under penalty 
of forfeit of their commissions as such. 

Market Vessels. 

Market vessels — meaning those which belong at the port, and which 
furnish daily supplies to vessels at anchor or in quarantine — shall, in 
ever}^ instance, apply to quarantine officer for permission before attempt- 
ing to trade or communicate with such vessels ; and in case of violation 
of this rule shall themselves be placed in quarantine and held at discre- 
tion of officer in charge. 

Vessels with Cargo to be Disinfected. 

Any vessels from infected districts which may desire to enter such 
cargo shall, upon arrival at outer bar, make known their intention to 
quarantine officer. Quarantine officers receiving this cargo at quarantine 
warehouse shall employ, as far as possible, only acclimatized men, and 
said employes shall be kept under quarantine themselves a sufficient 
number of days to determine their probable infection, their clothing and 
other articles capable of conve3ang infection be subjected to a high tem- 
perature, sa}^ 220 ° F. (105° C), before being allowed to return to cities 
or shore. The crews of said vessels shall be subject to rules as above, 
and such other precautions as may be deemed requisite at the time by 
State health officer. Costs in this instance, as in others, are chargeable 
to owners of cargoes. 

3. Quarantine Regulations at Pensacola, Florida. 

(Issued by the Escambia County Board of Health.) 

1. The port inspector shall visit and inspect every vessel entering 
the bay of Pensacola, and ascertain and report her sanitary condition ; 
and until such inspection and report, and the release of such vessel by 
said officer, no person shall visit her, and no person from her shall visit 



384 TEXT-BOOK OF HTGIEXE. 

any other vessel or the shore. The master or owner of each vessel so 
inspected shall pay to this Board for such services $5. 

2. Xo vessel coming into the port of Peiisacola, having on board 
any contagious or infectious disease, or from a port where any such dis- 
ease prevails, shall remain within the territory under the jurisdiction of 
this Board, except at a point designated and under restrictions imposed 
by this Board, according to the exigencies of each case. 

3. It shall be the duty of any person coming into the county of 
Escambia or port of Pensacola, from any locality where any disease in 
an epidemic form prevails, to report at once to this Board or some officer 
thereof, and no person coming from any such locality shall remain iu said 
county without the permit of this Board, and then only at such point as 
may be designated, and under such restrictions as may be imposed by 
this Board, according to the exigencies of each case. 

4. Xo ballast brought into the bay of Pensacola by vessels shall be 
discharged in the county of Escambia, or the waters separating that 
county and the county of Santa Rosa, except at such point as may be 
designated in a permit obtained from this Board or granted on its 
authority : and in case this Board or its sanitary inspector or other 
officer, with approval of this Board, deem it expedient for the preserva- 
tion of the public health to require fumigation, disinfection, or discharge 
of baUast at quarantine station, the same shall be done at the expense of 
the vessel, and in accordance with the system in use by this Board. 

5. All pilots and tow-boats of the port of Pensacola shall be sup- 
plied with copies of these rules, and every pilot or tow-boat master speak- 
ing or boarding a vessel coming into said port shall hand a copy thereof 
to the master of said vessel. 

6. In case any vessel shall be required, by authority of this Board 
in the exercise of its powers to preserve the public health, to discharge 
ballast at quarantine station or be fumigated, she shall pay 25 cents per 
ton for the ballast discharged, and for the fumigation shall pa}- as follows : 
Steam-ships. $75: ships, $50: barks and other vessels other than brigs 
and two-masted schooners, $40 ; brigs. $20 ; two-masted schooners, S15. 

T. Xo pilot, tow-boatman, or other person shall remove, transfer, 
or receive, or assist in removing, transferring, or receiving any person 
from any vessel entering the bay of Pensacola until such vessel shall 
have been inspected and released b}* the port inspector. 

QUARANTINE PRACTICE. 

The practical duties of administration, particularly the 
inspection and treatment of vessels, are well described by the 



QUARANTINE PRACTICE. 385 

medical officers in command of the several stations named in 
the following letters : — 

Gulf Quarantine Station, Chandeleur Island, Miss. 

(Letter from P. A. Surgeon H. R. Cakteu, U. S. M.-H. .S.) 

I board the incoming vessel while under way and give her such a 
berth as in my judgment is suital)le. 

When she is at anchor I first examine her papers, IjiUs of health, 
crew-list, and log ; questioning the master at the same time on such points 
as ma}' bear on the sanitary condition of his vessel; and, except in the 
case of Dr. Burgess's papers, given at Havana, far more valuable infor- 
mation will be given by, or may Ije extracted from, the master than is 
conveyed by the bills of health. The master is asked how long he lay at 
the port of clearance, especially where he discharged and where he lay; 
there being, for instance, as much differeiice in the liabilit}' to infection 
between different wharves in Havana, or between the Gamboa and the 
Coal Islands in Rio, as between different ports. 

I especially ask for the cause of discharge of men left (generally in 
hospital) at the port of clearance, and mark the substitutes shipped there 
for special examination. These men having probably been ashore for 
some time and quite frequently just out of hospital, where they were left 
by other vessels, are occasionall}- the means of introducing yellow fever 
aboard a vessel healthy until they are shipped. 

The statements of the master and even the log (except in British 
vessels) are naturally to be taken with some " personal correction " 
dependent on circumstances, and which has wide limits. In general, I 
think intentional false statements are extremely rare, but statements of 
damaging facts may not readily be volunteered. 

The vessel is then inspected. I go all over it, into every place, 
noting especially the sleeping-places and bedding, water-closets, character 
of ballast, and condition of the hold and forecastle, as regards cleanliness, 
ventilation, and dryness ; whether the air streaks are open ; if the ports 
have been open recently, or the wind-sails show signs of recent use. In 
the hold, aft and forward are most apt to be dirty. If the ballast has 
been recently trimmed and the crew is healthy it is a good sign ; on the 
other hand, it may account for a sudden outbreak of fever after she puts 
to sea, in a ship previously healthy. 

The bilge is examined by pumping, if in ballast ; b}' lifting a timber- 
plank if not ; and on the smell more stress is laid than on the color. 

I inspect the ship before I do the crew, so that I may see the crew 
when the}^ are not aware they are under observation. I then inspect the 
crew. All stand together, and as I call the roll each man answers, 

25 



386 TEXT-BOOK OF HYGIENE. 

comes to me, and passes to another place. Any I wish to examine more 
closely are told to step aside. These would in general be : Those who 
look sick, or as if they had been sick ; those who by the log or master's 
statement had been sick ; those who had shipped at port of clearance. 
They are examined as may be deemed necessary. In these cases little 
dependence can be placed on the accounts sailors give of their past ail- 
ments, and a kind of inverse malingering is universal. For instance, the 
cabin-boy of the " Maria," with yellow fever, was standing up, although 
holding by a chair, and reported himself as perfectly well and " could eat 
much," then staggered and had fallen had I not caught him in my arms, 
vomiting as he fell. 

We have no cargoes, save occasionally a schooner with fustic, log- 
wood, or sisal. 

The baggage is examined when unpacked for disinfection. 

If the vessel is infected and has sick men aboard, I attend to the 
sick first, and remove them if possible. Kight here I may sa}' that in 
some stages of yellow fever removal is not possible with safety to the 
patient — it means death to him. In this event, he should be isolated on 
board ship, having alread}" had the disease two or three da3's, and thereb}^ 
having already exposed the vessel. As soon as possible, however, he 
should be removed. 

A preliminary fumigation and disinfection is done immediately 
before doing anything else, in the hope of destroying the contagium at 
its source, and preventing the sickness of others of the crew. This is 
done as thoroughly as possible without removing ballast or much prelimi- 
nary mechanical cleaning, but particular attention being given to the 
probable source of infection. The vessel is then treated in the routine 
manner, as follows : — 

The bilge is first pumped out and washed until clean, after which 
the disinfectant is put in, — generally bichloride of mercur3^ At Chande- 
leur we have practically no cargoes to deal with. The ballast therefore 
is next removed. All sand, earth, porous stone, or other foul ballast is 
removed — thrown overboard. The work is done by the ship's crew. 
Clean, sharp stone — as much as may be necessar}^ to hold the vessel, i.e.^ 
prevent her capsizing — may be allowed to remain, each stone having 
been immersed in a 1 to 800 solution of bichloride of mercur3\ This is 
done by the crew while trimming ballast, — a necessar}- procedure, irre- 
spective of disinfection. The hold is washed down with sea-water by 
means of a force-pump, birch and whalebone brooms being also used, and, 
if necessary, scrapers. The same is done to the forecastle and other 
parts, if necessary. 

The vessel being mechanically clean in its accessible portions, the 



J 



QUARANTINE PRACTICE. 387 

disinfection is begun. All soiled or used clothing, and all bedding that 
can be so treated without destruction, is soaked for half an hour in 
bichloride solution. The remainder is hung up looselj" for fumigation. 
Not unfrequentl}^ there are articles — cotton-stuff comforts, etc. — which 
cannot be disinfected, and are, therefore, destroj'ed. All articles not 
capable of conveying infection, as chronometers and articles made from 
the precious metals, are removed. The cabin, forecastle, and hold are 
then fumigated. For close vessels the amount of sulphur used in the 
hold is 35 pounds per 100 tons. The cabin and forecastle are kept 
closed twenty -four hours, the hold from forty-eight to seventy-two hours. 
In an ordinarily tight ship it is impossible to enter the hold, even after 
sevent3'-two hours, until the fumes have been displaced by air from wind- 
sail and open ports. When the doors are opened all surfaces are washed 
with a solution of bichloride, either with hose and brooms or with mops. 
Gilt-work, being utterl}' destroyed by this agent, is washed with water as 
near boiling as it can be used. 

The quarantine detention of the vessel now begins. The proper 
time in quarantine is not less than the period of incubation. The number 
of daj^s of passage from foreign ports counts for nothing, as does also 
the time on the quarantine grounds previous to completion of dis- 
infection. 

In estimating the probability of a vessel being infected, it makes 
quite a difference whether the j^ellow fever she has had in passage devel- 
oped at such time that it could have been contracted elsewhere than on 
board ship, or so long after clearing as of necessit}' to have been com- 
municated by the ship or fomites aboard her. In the latter case she was 
infected. This has a direct bearing on her treatment. 

South Atlantic Quarantine Station, Blackbeard Island, Ga. 

(Description of Quarantine Methods, by Passed- Assistant-Surgeon J. H. White, U.S.M,-H.S.) 

On boarding a newly-arrived vessel, I first demand the crew-list and 
passenger-list (if an3^). I have the roll called, and, when all have 
answered, inspect each and every person, with a view to the discoverj^ of 
any signs of present or recently-passed sickness, of any character. 

The cabin, forecastle, galle}^, and an}^ other rooms are then in- 
spected, and every chest and locker opened and contents seen. 

The hold and between decks are next inspected. All sick are 
removed to hospital. 

This constitutes the first step. 

The second consists in putting into all these places a preliminary 
fumigation with sulphur of sufficient quantity, this process occupying 
about twenty-four hours. 



388 TEXT-BOOK OF HYGIENE. 

Third. — All ballast is removed when possible, and when not so it 
is dipped stone by stone in bichloride solution of the strength of 1 to 300 
or 1 to 500, and the whole vessel is washed as clean as water can make 
her, — hold, deck-houses, and all. 

Fourth. — Another, and even stronger fumigation than the first, 
with sulphurous-acid gas. 

Fifth. — With a force-pump and hose, a solution of bichloride 
(1 to 500, or stronger) is freely applied to every part of ship and con- 
tents. Clothing, both in use and not, is either burned, boiled, or soaked 
in a 1 to 500 solution of bichloride ; sometimes both the latter measures. 
Soaking lasts ten to fifteen minutes. Clothing is boiled twenty minutes; 
bedding two to three hours. Bedding is most often burned, and always 
after small-pox. 

Delaware Breakwater Quarantine Station. 

(Inspection and Treatment of Vessels, by William P. Orr, A. A. Surgeon U. S. M.-H. S.) 

The plan which I have followed in inspecting vessels at this station 
is as follows: — 

I first go down into the cabin and examine the bill of health (and 
manifest, if the vessel has a general cargo). From these I learn the 
following important facts : The sanitary condition of the port of depart- 
ure at the time of sailing ; the date of departure ; number of crew and 
passengers, and whether the vessel sails in quarantine or free pratique. 
I will say just here that the bills of health issued by Dr. Burgess, an 
Inspector of the Marine-Hospital Service, stationed at Havana, are the 
most complete and satisfactor}^ bills of health that I examine, and we 
have vessels coming to the Breakwater from all over the world. He 
alwaj^s gives the sanitary history and condition of the vessel, cargo, 
crew, and passengers, and the number of cases and number of deaths 
from contagious diseases during the week previous to the departure of 
the vessel. 

If on arrival there is no sickness on the vessel, and there has been 
none during the passage, and there is no infectious or contagious disease 
-at the port whence she sails, then the vessel is discharged from quaran- 
tine. If there is any contagious disease on board on arrival, the sick 
are brought ashore and cared for in hospital, and the vessel fumigated, 
disinfected, and detained for a variable period, usually ten days, in order 
to observe the crew and see whether an}'- new cases are going to appear. 
If the crew are all well on arrival, but have had sickness (b}^ sickness I 
mean yellow-fever, small-pox, or cholera) during the passage, the vessel 
receives the same treatment as above. In case the crew are all well, and 
there has been no sickness during the passage, but the vessel comes from 



SPECIAL MEASURES AGAINST CHOLERA. 389 

an infected port, then the treatment of the vessel depends upon the 
number of days' passage, the condition of the vessel, the statement of 
the captain (which is made under oath) as to whether the crew were 
allowed to visit the shore, and the length of time the vessel was in port 
discharging the cargo and reloading, and other considerations which 
enable us to decide whether any danger need be apprehended in allowing 
the vessel to enter. After careful inspection of a vessel from an infected 
port, if I find everything neat and clean, I usually allow her to proceed, 
provided she has had a passage of ten da}- s or more ; but if she has not 
been out for that length of time I detain the vessel, during the summer 
season, for observation until the ten da3^s from date of departure have 
expired. At the end of this time, if no sickness appear, the vessel is 
discharged. 

To clean an infected vessel, we begin the first day by fumigating, — 
that is, burn about 4 pounds of sulphur for every 1000 cubic feet 
of air-space, the hatchways, doors, and windows being closed and 
caulked, so as to make the hold, cabin, and forecastle as nearly air-tight 
as possible. The sulphur-fumes are allowed to remain in the hold twenty- 
four hours, and in the cabin and forecastle about ten hours; the second 
day all beds, pillows, and furniture which cannot be satisfactorily disin- 
fected are burned, and all clothing, blankets, curtains, carpets, and cotton 
and woolen goods are soaked in a bichloride solution (1 to 2000). The 
third day the floors, walls, and ceilings of the cabin and forecastle, and 
all furniture, drawers, and chests in them washed with the same solution. 
The vessel is now supposed to be clean, and is discharged at once, pro- 
vided the average period of incubation for the disease from which the 
crew have suffered has elapsed since there was any one sick on board. 

SPECIAL MEASURES AGAINST CHOLERA. 

Other features of quarantine administration are well ex- 
pressed in the following extract from the editorial pages of the 
Philadelphia Medical News of October 15, 1887, showing the 
measures necessary to extinguish an incipient epidemic of cholera 
and to prevent its spread. Such measures are as follow : — 

(a) Speedy recognition and isolation of the sick ; their proper 
treatment ; absolute and rapid destruction of the infectious agent of the 
disease, not only in the dejecta and vomit, but also in clothing, bedding, 
and in or upon whatever else it finds a resting-place. 

(6) The convalescents should remain isolated from the health}^ so 
long as their stools possibly contain an}^ of the infecting agent ; before 



390 TEXT-BOOK OF HYGIENE. 

mingling again with the well they should be immersed in a disinfecting 
bath, and afterward be clothed from the skin outward with perfectly 
clean vestments, which cannot possibly contain any of the infectious 
' material. 

(c) The dead should be well wrapped in cloth thoroughly saturated 
in a solution of corrosive sublimate (1 to 500), and, without delay, cortege^ 
or lengthy ceremonial, buried near the place of death in a deep grave, re- 
mote as possible from water which may, under any circumstances, be used 
for drinking, washing, culinary or other domestic purposes. (Cremation, 
of course, is by far the safest way of disposing of cholera cadavers.) 

{d) Those handling the sick or the dead should be careful to dis- 
infect their hands and soiled clothing at once, and especially before touch- 
ing articles of food, drinking, or culinary vessels. 

{e) In the case of maritime quarantine, the well should be disem- 
barked and placed under observation in quarters spacious enough to 
avoid crowding, and so well appointed and furnished that none will suffer 
real hardships. 

(/) Once having reached the station, those under observation 
should be separated in groups of not more than twelve to twenty-four, 
and the various groups should, under no pretext, intermingle. The quar- 
ters for each group should afford stationary lavatories and water-closets 
in perfect working condition, adequate to the needs of the individuals 
constituting the group, and supplied with proper means of disinfection. 
There should be a bed raised above the floor, proper coverings, and a 
chair for each member of the group, each person being required to use 
only his own bed. There should be a common table of sufficient size to 
seat around it all the members of the group, who should be served their 
meals from a central kitchen, and with table furniture belonging to the 
station and cleaned by the common kitchen scullions. 

{g) Drinking-water, free from possible contamination and of the 
best quality, should be distributed in the quarters of each group as it is 
needed, and in such a manner that it is received in drinking-cups onty. 
There should be no water-buckets or other large vessels in whicli hand- 
kerchiefs, small vestments, children's diapers, etc., can be washed by the 
members of any group. 

(Ji) Immediately after being separated into groups in their respec- 
tive quarters, every person under observation should be obliged to strip 
and get into a bath (a disinfecting one is preferable), and afterward be 
clothed with fresh, clean vestments from the skin outward. Every article 
of clothing previously worn should be taken away and properly disin- 
fected. 

(i) Then all of the personal effects should be at once removed to a 



SPECIAL MEASURES AGAINST CHOLERA. 391 

separate building, washed (if possible), and thoroughly disinfected, or, 
if necessary', destro3'ed. After disinfection they should be temporarily 
returned to the members of groups, when occasion requires a further change 
of clothing. 

{k) Under no circumstances whatever should washing of clothing 
b}' those under observation be permitted. All used clothing should be 
first thoroughly disinfected (by boiling, M^ien possible), and then should 
be cleansed, the disinfection and washing being done by a sufficiently 
trained and absolutely reliable corps of employes supplied with adequate 
appliances. 

(l) All those under observation should be mustered in their own 
quarters, and be subjected to a close medical inspection, while on their 
feet, at least twice every day, in order to discover and isolate, as soon as 
possible, new cases which ma}' develop ; and, of course, the clothing and 
bedding of these new cases should be treated without delay in the manner 
already mentioned. In the meantime, a watch should be set over the 
water-closets for the purpose of discovering cases of diarrhoea, and, when 
discovered, such cases should be temporarily separated from the rest. 
They should receive judicious medical attention at once, and precautions 
should be taken as if they were undoubted but mild cases of cholera. 

(m) The quarters should be kept thoroughly clean, and every sur- 
face upon which infectious material could possibly be deposited, includ- 
ing the floors, should be washed with a strong disinfectant twice daily, 
and oftener when necessarj'. Evacuations from the bowels should be 
passed into a strong disinfectant ; the hopper of the closet should be 
then flushed and finally drenched with a quantity of the same dis- 
infectant. 

(«) For the proper attention to the sick, there should be two or 
more competent and experienced physicians, assisted b}^ a sufficient corps 
of intelligent and efficient nurses, with hours of duty so arranged that a 
physician, with a sufficient number of nurses, be in constant attendance 
in the wards of the hospital. 

(o) For the prompt recognition and separation of new cases, their 
temporary medical attention, the proper treatment of discovered cases 
of diarrhoea or cholerine and of other maladies, and the immediate cor- 
rection of every insanitar}' practice or condition by constant, vigilant, and 
intelligent supervision, there should be at least two or more competent 
and experienced physicians, with hours of service so arranged that a phy- 
sician is on duty night and day among those under observation; and he 
should have, subject to his orders at any and ever}^ moment, a sufficient 
and efficient corps of nurses and laborers to carry out properly and 
promptly his directions. 



392 TEXT-BOOK OF HYGIENE. 

(p) In order to prevent the intermingling of the various groups, to 
enforce obedience and order, and to make it absolutely impossible for the 
quarantined and their personal effects to have any communication with 
the exterior, a well-organized and sufficiently large police corps should 
patrol the borders of the stations and the buildings day and night. 

{q) Any group among whom there have developed no new cases of 
cholera or of choleraic diarrhoea, during the preceding eight or ten days, 
may be regarded as harmless, and allowed to leave quarantine after each 
one is finally immersed in a disinfecting bath and re-clothed with clean 
garments from the skin outward, the garments removed being destroyed 
or thoroughly disinfected and cleansed, as already indicated. 

As yet no reference has been made to the crew, ship, and cargo. 
What has been said of the treatment of those under observation apjjlies 
to every one of the ship's inhabitants. The observation, isolation, and 
cleansing of the crew and their effects could safely be performed aboard 
ship if necessary. The ship should be thoroughly cleansed and disin- 
fected, particular attention being given to the quarters of the emigrants 
and crew. 

AIDS TO QUARANTINE. 

In aid of the national quarantines, sanitary inspectors are 
appointed by the Marine-Hospital Service at special points of 
danger, either in the United States or abroad. Through the 
State Department consular notification from foreign ports is 
received regularly by mail, or, in emergency, by cable, and the 
information thus received, and that received also from home 
ports, is communicated, by the Marine-Hospital Bureau, to all 
quarantine authorities and others, by means of a weekly pubH- 
cation known as the "Abstract of Sanitary Reports." 

An important source of information concerning the move- 
ments of vessels in every portion of the world is the "Maritime 
Register," published in New York. The United States Col- 
lectors of Customs are efficient aids, having, by law, the power 
of search and detention of vessels, and having exceptional 
knowledge of the sanitary condition of the shipping at their 
respective ports. The Revenue-Cutter Service, a national coast 
patrol, renders efficient aid, and the light-house establishment 
and coast survey render valuable assistance in locating and 
buoying the anchorages. 



INLAND QUARANTINE. 393 

Finally, the Marine-Hospital Service, having, besides the 
quarantines, the care of the sick of the merchant vessels of the 
United States, with 126 physicians stationed at all the larger 
and many of the smaller ports, is ready at a moment's notice to 
extend indefinitely its quarantine service. To the surgeon- 
general of this service, at Washington, are entrusted all national 
quarantine matters. 

INLAND QUARANTINE. 

Under Inland Quarantine will be mentioned The Sanitary 
Cordon, Camps of Probation, Railroad Quarantine, Disinfection 
Stations, and Inspection Service. 

The Sanitary Cordon. — This consists of a line of guards, 
military or civil, thrown around a district or locality, either to 
protect the same from the surrounding country Avhen infected, 
or to protect the surrounding country from the infected district 
or locality. When a given locality is infected, and the adjacent 
territory is regarded as suspicious, it may be necessary to establish 
a double cordon, the first one embracing the whole suspected 
territory at its outer edge, the second investing more closely the 
well-defined infected locality. After the expiration of a sufiicient 
time to prove that the area between the cordons is not infected, 
or has been cleared of infection, the first cordon may be re- 
moved. Hospitals and camps of probation may be necessary 
adjuncts to the cordon. The most noted example of the sanitary 
cordon is found in the history of the plague epidemic in Russia 
in 1878. A colony on the river Volga, called Wetljankaja, with 
a population of 1700 inhabitants, became infected with the 
Oriental plague, which extended to the neighboring villages. A 
military cordon was made to embrace all the infected district. 
The inhabitants of the focus of infection, Wetljankaja, were 
removed, property appraised for re-imbursement by the govern- 
ment, and the village burned. An additional cordon was thrown 
around Zarizin, a neighboring commercial city of importance 
and terminus of the Russian railway system. The cordons were 
maintained several months, and the plague was stamped out. 



394 TEXT-ROOK OF HYGIENE. 

(See Abstract Sanitary Reports, vol. i [Bulletin's], page 78.) 
The sanitary cordon is the customary method of preventing the 
spread of epidemic disease in the eastern countries. 

In the United States, when yellow fever prevailed in Pen- 
sacola in 1882, to the extent of 2200 cases, the navy-yard 
reservation, whose boundary-line is within two miles of the city 
limit, wdth a population of about 1500, was successfully guarded 
by means of a cordon and non-intercourse. 

The following year, 1883, the navy=yard itself was infected, 
and a cordon was thrown around it to protect the city of Pen- 
sacola, and was maintained for a period of sixty days. This 
cordon was under the management of the Surgeon-General of the 
Marine-Hospital Service, aid having been requested of the na- 
tional government. The Collector of Customs of Pensacola 
was made the agent to execute the orders of the Marine-Hospital 
Bureau, and to the president of the local Board of Health was 
entrusted the immediate command of the line and guards. The 
cordon entirely surrounded the land boundary of the naval 
reservation. Its line was four miles in length, one mile of it 
through a dense thicket, and was marked by blazed trees and 
flags. Forty men were employed as guards, an equal number 
being selected from each of the two political parties. Two cap- 
tains were appointed, and were obliged to supervise the line 
night and day. 

The sentinel posts were furnished with tents, and two guards 
were allotted to each post, taking alternate watches of four 
hours each. A detention or probation camp was established 
and placed in charge of a physician, where persons wishing to 
leave the reservation were obliged to pass a probationary period 
of twenty days. Not more than half a dozen persons were 
received in this camp. The government expended about 
$20,000 in these restrictive measures, which were entirely suc- 
cessful. Not one person got through the cordon line. The 
success was due largely to the thorough discipline maintained 
by the Collector and the President of the Board of Health. 



INLAND QUARANTINE. 395 

Yelloic- Fever Cordon in Texas. — In 1882, yellow fever pre- 
vailing in Mexico along the Rio Grande, and in Brownsville, 
Texas, a sanitary cordon was established by the Surgeon-General 
of the Marine-Hospital Service, on request of tlie Governor of 
the State, extending along the line of the railroad from Corpus 
Christi, on the Gulf of Mexico, inland to Laredo, on the Rio 
Grande. This line was 180 miles northeast of Brownsville, the 
triangular territory thus hemmed in by the cordon on one side, 
the Rio Grande on another, and the Gulf on the third, being all 
suspected territory, although the fever prevailed in only one 
corner of it, viz., in Brownsville. x\ll persons were detained at 
least ten days at the cordon before being allowed to pass north- 
w^ard, — a period of probation to insure that no one having the 
disease should carry it farther north. As soon as practicable 
another cordon was established much nearer to Brownsville, 
only 30 miles from it, the line extending from the mouth of the 
Sol Colorado, on the Gulf of Mexico, to Santa Maria, on the 
Rio Grande. After a time sufficient to prove that no more 
fever prevailed between the two cordons, the first one w^as 
removed. Within the second line, where the fever prevailed, 
chiefly in Brownsville, a hospital was established and dispensa- 
ries opened for the gratuitous treatment of all applicants. 

Upon the Mexican side of the Rio Grande the fever con- 
tinued to spread northwardly, and, in order to oppose it, still 
another cordon had to be established on the American side of 
the river, extending from Santa Maria on the south to Laredo 
on the north, a distance of 500 miles. Three hundred guards 
well mounted (Texan cow-boys) were employed in this cordon, 
and, while the disease was being stamped out in Brownsville, 
any further importation from Mexico was thus prevented. In 
Mexico the fever continued to spread until the authorities finally 
adopted measures similar to the above. 

Much violent language has been used concerning the hard- 
ships imposed by the sanitary cordon, but in the presence of an 
epidemic the authorities who are responsible need to pay more 



396 TEXT-BOOK OF HYGIENE. 

lieed to the efficiency of the cordon than to individual com- 
plaints. It should be borne in mind that the sanitary cordon is 
not intended to bottle up all the people who are caught within 
an infected district. On the contrary, it is intended as a means 
of exit to those who will not carry with them contagious disease 
to the people beyond. 

The cordon, then, imposes simply a period of detention 
corresponding to the incubative period of the prevailing disease. 
Ample preparation must be made for housing and feeding, in 
camps or other quarters, persons awaiting the expiration of the 
detention period ; and hospitals must be provided for the treat- 
ment of those who develop sickness. Provision must also be 
made for the disinfection of suspected baggage. 

Camps of Probation. — Camps of probation or detention 
should be established with all the precision of arrangement 
and regard for site, water, and drainage that pertain to a military 
camp. Every effort should be made to make the camp as com- 
fortable and cheerful as possible, and to this latter end amuse- 
ments and entertainments such as might be suggested by the 
campers themselves should be encouraged. Every necessity in 
the matter of food, bedding, and the ordinary comforts of life 
should be anticipated to prevent any just cause of complaint. 
Such a natural division of the inhabitants should be made as 
seems desirable at the time, those of equal intelligence and 
refinement naturally seeking each other's company. The greatest 
concern is to prevent the camp itself from becoming infected. 
To this end no baggage should be allowed within the camp 
boundary without previous disinfection ; and every refugee 
should be examined by a physician before being admitted to the 
camp. No one should be received who does not intend to pro- 
ceed to an uninfected locality after his probation. In other 
words, a camp of probation should not be used as one of 
refuge. 

The camp must be surrounded by guards to prevent egress 
or ingress, excepting through the established portal. At least 



INLAND QUARANTINE. 397 

twice or three times in the twenty-four hours all refugees should 
be inspected in their quarters, and any case of sickness at once 
be isolated and watched until the diagnosis is certain. If the 
case is one of the prevailing disease, the patient must be re- 
moved immediately to the hospital, which should be at a safe 
distance, half a mile or more, from the camp. Before leaving 
the camp, each refugee's clothing should be fumigated, and he 
should be given a certificate that he has passed the required 
period of probation. A clear distinction must be made between 
camps of probation and camps of refuge. Camps of refuge are 
simply residence camps established to receive the population of 
an infected community when it has been determined to depopu- 
late the infected district. 

Depopulation of a house, a block, a district, or a whole 
city, if possible, the people moving into camps, is now recog- 
nized as a valuable means of controlling an epidemic ; and 
there may be either camps of probation or simply camps of 
refuge, or both, according to the requirements of the situation. 
Camps of refuge, in connection with depopulation, were sug- 
gested by the late Surgeon-General Woodworth, in 1878, and 
the measure was practically carried out at Memphis, in 1879, 
by the establishment of Camp Mitchell. " But the establish- 
ment of a camp to which persons from infected points could go, 
be kept under observation a sufficient length of time to demon- 
strate they were not infected, have their baggage disinfected, 
and be given 'free pratique,' is apparently a new departure in 
inland quarantine." 

Camp Perry ^ Fla. — Such was Camp Perry, Florida, de- 
scribed by the surgeon in charge, W. H. H. Hutton, in the 
Marine-Hospital Service Report for 1889. The site w^as admir- 
ably chosen by Passed- Assistant-Surgeon John Guiteras, upon a 
bluff on the south side of St. Mary's Biver, the dividing line 
between Florida and Georgia, about forty miles north of Jack- 
sonville, Fla., which city was in the throes of a yellow-fever 
epidemic. The camp was opened August 20, 1888. It con- 



398 TEXT-BOOK OF HYGIENE. 

sisted, in its completed stage, first, of 50 wooden cottages built 
elsewhere and transported on cars. Their dimensions were 12 
feet by 10, and 10 feet in height, constructed of plain lumber, 
with cracks battened, and windows on each side with swinging 
shutters. Each held four cots, chairs, and toilet-stand, while 
unused clothing was neatly arranged on the rafters above. 
Besides the 50 cottages there were a quartermaster and guard- 
house, commissary building, dining-room, and kitchen, and 
laundry, built of rough lumber; 2 Ducker portable barracks, 
each 18 by 35 feet, provided with 12 beds each, and 350 tents, 
used principally by the single men, the employes and guards, 
and the colored refugees. The camp was laid out and its 
military discipline established under the temporary personal 
command of Surgeon-General Hamilton. So far as known this 
is the first camp of the kind ever established, at least in the 
United States. The cottages were arranged in a quadrangle 
around a parade-ground two acres in extent, and the tents were 
arranged in streets and alleys in the rear of the cottages. The 
accommodations were sufficient for 600 people, and extra tents 
were on hand so that if required 1000 persons could have been 
provided for, or 3000 per month, allowing for only ten days' 
detention of each person. Two hundred hospital- tents will 
accommodate 1200 people comfortably, according to Surgeon 
Hutton, who states that the small A-tents are unsuited for 
women and children, but will answer for men or boys. Wire- 
mattress cots should be provided. The marine-hospital officer 
at Savannah, Ga., was the purchasing agent for the camp, and 
promptly forwarded all subsistence supplies on requisition by 
mail or telegraph. 

Discipline of the Camp. — On arrival of a train, each pas- 
senger was personally examined by a physician, his liealth- 
certificate scrutinized, and he was made to await the examination 
of others. Hand-bags, clotliiug, and loose wearing-apparel 
were left in the baggage-car for disinfection. The refugees were 
then marched to the quartermaster's room for registration and 



INLAND QUARANTINE. 



399 



assignment to quarters. On first arrival they were placed in the 
southern part of the camp, and in two days, there being no 
sickness, were moved forward several cabins, and this progres- 
sion was repeated until the time for discharge. 

Twelve guards were employed, under the command of a 
captain, and were divided into squads of four each. The 
schedule was so arranged that each guard was on duty two 
hours and off duty four. 

A bugler announced the several calls as follows : — 



5.30 A.M., . 






Reveille. 


6.00 A.M., . 






Breakfast, emplo3'es. 


7.00 A.M., . 






Breakfast, guests. 


9.00 A.M., . 






Surgeon's call and inspection. 


12.00 M., . 






Dinner, employes. 


1.20 P.M., . 






Dinner, guests. 


4.30 P.M., . 






Surgeon's call and inspection. 


6.30 P.M., . 






Supper, guests. 


6.00 P.M., . 






. Supper, employes. 


6.30 P.M., . 






. Retreat and change of guard. 


9.00 P.M., . 




. 


. Retiring taps. 



The yellow-fever hospital-camp, under the special charge 
of Dr. Faget, was located one-half mile from the probation 
camp. It consisted of 2 frame buildings, 2 hospital and 12 
smaller tents, arranged in a double-crescent shape, the avenue 
in the middle presenting an attractive appearance. 

Of the 12 small tents, 4 were for nurses, 3 for employes, 
2 for convalescents, and 1 each for drug-store, storage- and 
dead- house. One of the hospital-tents was used as a dining- 
room for employes, convalescents, and parents of the sick. 

The hospital was established September 3, 1888, and be- 
tween that date and November 24th 35 cases of yellow fever 
were admitted and treated, 3 died, and 32 were discharged. 
Twelve hundred and eleven refugees were received into Camp 
Perry, nearly all of whom were from the infected district of 
Jacksonville. 

Thirty-five cases of yellow fever were caught by the ten 



400 TEXT-BOOK OF HYGIENE. 

days' detention, but no case of fever was contracted at the camp, 
and of the 1208 refugees who passed the required detention and 
proceeded to different parts of the country, so far as known, not 
one subsequently developed or carried the disease elsewhere. 
The general plan of the preventive measures adopted during this 
epidemic will be described under Railroad Quarantine. 

Railroad Quarantine, Inspection Service, and Disin- 
fection Stations. — Railroad quarantine, disinfection stations, 
and inspection service may be described by a brief account of 
the actual measures of this nature, made use of during the 
yellow-fever epidemic in Florida in 1888, of which Camp Perry, 
just described, was an important adjunct. (For details, see 
annual reports marine-hospital service, 1888 and 1889.) 

The Governor of Florida made application to the national 
authorities, July 16th, for aid, and it was determined to prevent 
further spread of the disease by disinfecting all baggage from 
infected localities before permitting its transportation into other 
States, and by enforcing upon all persons from infected localities 
seeking to leave the State a probationary detention of ten days. 

Accordingly, disinfection-stations were established at two 
points, through which all persons leaving Florida by rail were 
obliged to pass. One of these was at Live Oak, in Xorth western 
Florida ; the other at Way Cross, Georgia, near the boundaiy- 
line of Northeastern Florida. The only other means of egress 
from the State was from the sea-ports; but healthy sea-ports 
maintained a vigorous quarantine against people from the in- 
fected districts, and infected sea-ports were not visited by the 
steam-ship lines, because their vessels would thereby be made 
liable to quarantine detention at other ports. The fumigation 
of baggage at Live Oak and Way Cross was accomplished by 
means of box-cars specially prepared, and subsequently in 
warehouses, the agent being sulphur dioxide. 

Regarding persons, the inspectors, properly uniformed and 
wearing official shields, boarded the trains when the latter arrived 
at the inspection-stations, and demanded of each passenger a 



INLAND QUARANTINE. 401 

certificate, showing where he had been during the previous ten 
days, which certificate was considered vaUd only when it bore 
tlie seal or signature of some officer of health, or recognized 
municipal authority. The inspectors themselves were kept 
informed regarding all infected or suspected localities, and a 
person coming from such locality was either made to return to 
it, or given the option of going to the camp of probation, there 
to spend the ten days' period of probation before being allowed 
to €nter other States. 

This was Camp Perry, previously described, located 38 
miles south of the Way Cross Station, and 40 miles north of 
Jacksonville, where the epidemic prevailed chiefly. All egress 
from Jacksonville was, perforce, through Camp Perry and its ten 
days' probation. 

This camp was a means of protecting not only other States, 
but the uninfected portions of Florida itself, more particularly 
Southern Florida, whose health authorities refused to admit 
within their limits the refugees from the infected districts unless 
they had passed the period of probation at Camp Perry, To 
assist in this protection to Southern Florida, no person w^as 
allowed to board a south-bound train between Way Cross, 
on the north, and Orange Park, a station 20 miles south of 
Jacksonville. 

Moreover, through south-bound trains were boarded at 
Way Cross, and all passengers compelled to furnish evidence of 
coming from healthful localities. The evidence consisted of 
certificates from local authorities, baggage-checks, or railroad- 
tickets showing they were purchased in the North, and in some 
instances letters showing by the superscription and stamps where 
the person had been. 

No train, excepting the special government train, was 
allowed to stop at Camp Perry. A government train also 
carried those who had passed the period of probation from Camp 
Perry to a point 3 J miles distant, Folkstone, where they were 
transferred to a regular train running as far north as Way Cross, 

26 



402 TEXT-BOOK OF HYGIENE. 

Ga., where another transfer had to be made to a regular north- 
bound train. No Florida passenger-car was allowed to go north, 
and more than 1000 baggage and freight cars were disinfected 
by government officers before being allowed to leave the State. 

The methods of railroad quarantine may also be studied 
in a review of the action taken to prevent the introduction of 
small-pox into the United States from Canada, where it prevailed 
extensively in the fall and winter of 1885, and January and 
February, 1886. 

The following regulations were issued by the Surgeon- 
General of the Marine-Hospital Service, October, 10, 1885 : — 

The act approved April 29, 1878, entitled, " An act to prevent the 
introduction of contagious or infectious diseases into the United States," 
provides that no vessel or vehicle coming from any foreign port or 
country where any contagious or infectious disease exists, or any vessel 
or vehicle conveying persons, merchandise, or animals affected with an}' 
contagious disease, shall enter any port of the United States, or pass the 
boundary-line between the United States and any foreign country, except 
in such manner as may be prescribed under said act. 

Attention is now directed to the prevalence of the contagious and 
infectious disease of small-pox in Montreal and other places in the 
Dominion of Canada, and the law referred to is held to apply alike to 
trains of cars and other vehicles crossing the border, and to vessels 
entering ports on the northern frontier. 

Because, therefore, of the danger which attaches to the transporta- 
tion of persons and baggage, and articles of merchandise, or animals, 
from the infected districts, the following regulations are framed, under 
the direction of the Secretary of the Treasury, and subject to the 
approval of the President, for the protection of the health of the people 
of the United States against the danger referred to : — 

1. Until further orders all vessels arriving from ports in Canada, 
and trains of cars and other vehicles crossing the border-line, must be 
examined by a medical inspector of the Marine-Hospital Service before 
they will be allowed to enter the United States, unless provision shall 
have been made by State or municipal quarantine laws and regulations 
for such examination. 

2. All persons arriving from Canada, by rail or otherwise, must be 
examined by such medical inspector before they will be allowed to enter 
the United States, unless provision has been made for such examination. 



INLAND QUARANTINE. 403 

3. All persons coming from infected districts, not giving satis- 
factory evidence of protection against small-pox, will be prohibited from 
proceeding into the United States until after such period as the medical 
inspector, the local quarantine, or other sanitary officer duly authorized, 
may direct. 

4. The inspectors will vaccinate all unprotected persons who desire, 
or are willing to submit to, vaccination free of charge. Any such person 
refusing to be vaccinated shall be prevented from entering the United 
States. 

5. All baggage, clothing, and other effects, and articles of mer- 
chandise, coming from infected districts, and liable to carry infection, or 
suspected of being infected, will be subjected to thorough disinfection. 

6. All persons showing evidence of having had small-pox or vario- 
loid, or who exhibit a well-defined mark of recent vaccination, may be 
considered protected, but the wearing-apparel and baggage of such pro- 
tected persons who may come from infected districts, or have been 
exposed to infection, will be subjected to thorough disinfection as above 
provided. 

7. Customs officers and United States medical inspectors will con- 
sult and act in conjunction with authorized State and local health author- 
ities so far as may be practicable, and unnecessary detention of trains or 
other vehicles, persons, animals, baggage, or merchandise, will be avoided 
so far as may be consistent with the prevention of the introduction of 
diseases dangerous to the public health into the United States. 

8. Inspectors will make full weekly reports of services performed 
under this regulation. 

9. As provided in Section 5 of said act, all quarantine officers or 
agents acting under an}^ State or municipal sj^stem, upon the application 
of the respective State or municipal authorities, are empowered to en- 
force the provisions of these regulations, and are hereby authorized to 
prevent the entrance into the United States of any vessel or vehicle, 
person, merchandise, or animals prohibited under the act aforesaid. 

10. In the enforcement of these regulations there shall be no inter- 
ference with any quarantine laws or regulations existing under or to be 
provided for by any State or municipal authority. 

The following are the special instructions for the guidance 
of sanitary inspectors, issued by Surgeon H. W. Austin, in 
charge of the inspection service on the Canadian frontier from 
Buffalo, N.Y., to the Atlantic coast during the epidemic above 
referred to (See Marine-Hospital Report, 1886): — 



404: TEXT-BOOK OF HYGIENE. 

Regulations for Sanitary Inspectors. 

The following instructions will be observed by the sanitary inspector 
on the following-mentioned railroads crossing the United States boundary- 
line, viz., the Grand Trunk Railwa}^, at Rouse's Point, N. Y., and 
Island Pond, Yt. ; the Passumpsic Railroad, at Newport, Yt.; the Cen- 
tral Yermont Railroad, at Highgate Springs or Saint Albans ; the Canada 
Atlantic, at Rouse's Point, N.Y. ; and the Southeastern Railway, at 
Richford, Yt. :— 

All persons bound for the United States coming from Montreal, or 
other places in Canada where small-pox prevails, must produce satisfac- 
tory evidence to the inspector that they are protected by a recent vaccina- 
tion, or submit to this operation before they are allowed to cross the 
boundary-line. 

Inspectors will vaccinate all unprotected persons free of charge. 

Persons coming from Montreal, or suburban villages, will be care- 
fully questioned as to their residence, whether small-pox has occurred in 
their families, or whether they have been in contact with the disease. 

Inquiries should also be made relative to their baggage, whether it 
consists of bedding, household goods, etc., likely to be infected ; and if 
any person or article of baggage is considered by the inspector infected 
or likely to introduce the disease into the country, he or it should not be 
permitted to cross the line into the United States. 

You may consider persons protected who may show evidence of 
having had the small-pox or varioloid, or who exhibit a well-defined mark 
of vaccination. Accept as evidence of protection a certificate from any 
physician in good standing that the person presenting the same has been 
successfully vaccinated. Should you doubt the validity or authenticity 
of the certificate, you may refuse any such person presenting the same 
the privilege of crossing the border unless he submits to vaccination. 
Baggage known to have come from any infected district, and believed to 
be infected, will be thoroughly fumigated with sulphur at Rouse's Point, 
Saint Albans, Richford, Newport, and Island Pond. 

Weekly reports should be made to Surgeon H. TV. Austin, United 
States Marine-Hospital Service, Burlington, Yt., of the number of trains 
inspected, number of persons examined, number of persons vaccinated, 
number of pieces of baggage fumigated, and any other information 
relative to services performed by the inspector. 

It will be observed tbat all the railroads, five in number, 
over which passengers or freight might be brought direct from 
Canada into the New England States were guarded. 



\ 



INLAND QUARANTINE. 405 

Besides the line commanded by Surgeon Austin (Atlantic 
coast to Buffalo), another line was under the direction of Passed- 
Assistant-Surgeon Wheeler, at points east of Buffalo, and still 
another on the Michigan frontier, under command of Surgeon 
W. H. Long. These lines were established at the request and 
with the co-operation of the authorities of the respective States. 
Thirty-six inspectors w^ere employed at 37 stations, who exam- 
ined 49,631 persons on railroad-trains, vaccinated 16,547, and 
detained or sent back 603. The contents of more than 7000 
pieces of baggage were disinfected. The measures taken were 
successful. 

The following are the rules for railroad quarantine adopted 
by the Quarantine Conference held in Montgomery, Ala., March 
5th to 7th, 1889:— 

1. Quarantine should not be made against anj^ place until it is 
officiall}^ known that j^ellow fever or other infectious or contagious dis- 
ease exists at such place. 

2. Only competent physicians should be put in charge of quaran- 
tine stations, and only thoroughl3'-qualified persons should be emplo^'ed 
as inspectors on railwaj^-trains. 

3. Quarantine stations located on railroads should be established 
at convenient points, on one or both sides of a town or station, as may 
be deemed necessar}^ 

4. If an epidemic of yellow fever or other infectious or contagious 
disease exist at a town or station, trains carrying passengers or freights 
should be required to pass through the limits of such towns or stations 
at a speed of not less than ten miles per hour, without stopping at such 
towns or stations, but should stop at the quarantine station. 

5. Passengers to or from such infected point should only be received 
or delivered at the quarantine station, under the supervision of the quar- 
antine oflScer in charge of the station. 

6. Railway-tickets may be sold to persons leaving an infected place 
to any point willing to receive them. 

1. All baggage from any infected point should be properly disin- 
fected. 

8. As far as practicable, the same rules proposed for railroads 
should be applied to vessels of every kind, stage-coaches, or other means 
of travel. 



406 TEXT-BOOK OF HYGIEXE. 

9. The passage of railroad-trains through any point on the line of 
road, whether infected or not, should not be prohibited by any quaran- 
tine regulations. The conductors of passenger-trains should close the 
windows and ventilators and lock the doors of cars passing through any 
place where a train is not permitted to stop. 

10. All freight to any infected place should be delivered either at 
the quarantine station or the nearest railway-station to such infected 
point where it can be properly cared for. 

11. All mail-matter from any infected place should be properly 
disinfected by the United States Government ; and mail-matter intended 
for infected points should be put off the trains at the quarantine stations. 
The United States Government should instruct postmasters to receive 
and deliver mails at such quarantine stations. 

12. Railroads and express companies ma}^ receive for transporta- 
tion from any infected place, during the time such infection exists, any 
merchandise or traffic consigned to places willing to receive it. 

13. State authorities should emplo}^ competent persons on passen- 
ger-trains as inspectors of passengers, baggage, and express matter, as 
additional precaution; but the fact of inspectors being on such trains 
should not relieve trains carrying passengers or express matter or 
baggage from stopping at quarantine stations for such inspection as the 
officer in charge may determine to be necessar}^ 

14. It is recommended that all quarantines, as far as practicable, 
should be uniform in their requirements and operations, which will 
greatly contribute to the prevention of panics, and tend to allay un- 
necessary excitement and fear on the part of the people. 

15. The form of health certificate adopted by the Quarantine Con- 
vention, held at Montgomery, March 5, 1889, should be prepared for 
health officers to issue to such persons as ma}^ be found entitled to re- 
ceive the same. A copy of this certificate should be printed with these 
rules, and conspicuously posted at railway-stations. 

16. It is the desire and intention of health authorities, as far as 
practicable, to throw every safeguard around the public health of all 
localities. Municipal, county, and State authorities are expected to 
co-operate in every possible way with health officers located in towns, 
villages, and cities, and in charge of quarantine stations, to enable them 
to prevent the introduction or spread of yellow fever or other infectious 
or contaorious diseases. 



It was also resolved by this conference that the best form 
of disinfectant for personal baggage is moist heat. 



MUNICIPAL, STATE, AND NATIONAL QUARANTINE LAWS. 407 

CORRELATION OF MUNICIPAL, STATE, AND NATIONAL QUARANTINE 

LATTS. 

As shown in the foregomg pages, quarantines are admin- 
istered under three forms of government, — local. State, and 
national. A vessel arriving at a given port may he refused 
permission to discharge cargo by authority of either a national 
statute, a State law, or a city ordinance. At Brooklyn, for 
example, if the United States officers should consent to a vessel's 
entry and discharge, restraint could still be imposed by the State 
officers ; and if the latter also should consent, the city author- 
ities could still prevent. In some instances, as at Philadelphia 
and New Orleans, municipal officers are included in the State 
quarantine boards, and harmony of action between city and 
State is thus assured. But, unfortunately, there are still a few 
States which exercise either little or no supervision of quaran- 
tines, so that a county or village quarantine may be purely a 
local aifair conducted without regard to neighboring counties or 
villages or to the rest of the State. It is this form of quarantine 
which, in times of epidemic and panic, has for so many years 
wrought untold misery, which has given rise to the shot-gun 
quarantines, checked all the currents of trade and social inter- 
course, arrayed county against county, village against village, 
and turned the hand of neighbor against neighbor in a ferocious 
struggle to ward off the pestilence. 

Instances of this form of quarantine were numerous in the 
Southern States during the yellow-fever epidemic of 1878, when 
the policy of non-intercourse between communities was so rigidly 
enforced that many were cut off from subsistence supplies, and 
there was danger of starvation. 

Much has been written upon the folly of the shot-gun 
quarantines, yet communities employing this method have, under 
their peculiar circumstances, acted wisely, and the results, as 
compared with those of similar communities neglecting this 
method, have demonstrated its merit. The blame for all the 
hardships and suffering entailed is to be laid upon those whose 



408 TEXT-BOOK OF HYGIENE. 

business it is to make the laws of the State. In the States in- 
dicated there were no State boards of health, or they were 
clothed with but little authority, or, being formed in conjunction 
with the board of some principal sea-board city, gave little atten- 
tion to inland districts. 

The most recent illustration of the difficulties made by 
local quarantines, without State supervision, was in Florida 
during the yellow-fever epidemic of 1888, when the whole 
State, there being no central sanitary authority, was in confusion 
through the enactments of village, county, and city boards of 
health, all acting independently, with no common plan or guid- 
ance. When finally, by request of the Governor, the United 
States authorities assumed control, the petty enactments of these 
small local boards, and their adherence to their rights, gave 
great trouble to the government officers, some of whom ex- 
perienced great delay and personal hardships in gettmg through 
the local lines to the points of danger and activity to which they 
had been ordered. This epidemic demonstrated clearly the need 
of a State board of health, which the Legislature has since 
established. State boards of health do not do away with local 
boards, but make them work in harmony on broad plans laid 
down in the interest of all. 

But there are States which yet have no boards of health, 
where, in case of epidemic, the old confusion might arise were 
it not for a new exercise of power on the part of the national 
government, made possible by the Act of Congress, approved 
March 28, 1890, known as the Interstate Quarantine Act, to 
which further reference will be made. 

Having shown the necessity of State supervision over 
village and county quarantines, it is now pertinent to consider 
the relation of the States to one another. Theoretically, in 
maritime quarantine, there is opportunity for clashing. One 
State might be very rigid in its exactions, while a neighboring 
State, owing to financial stringency, indifierence, or a desire to 
divert the commerce of the first to its own ports, might be very 



MTXICIPAL, STATE, AXD XATIOXAL QUARAXTIXE LAWS. 409 

lax. On this account, and to secure uniformity of procedure, 
it has been urged that all maritime quarantines should be given 
over to the national government. It is not intended to enter 
into this subject exliaustively, but it may be remarked that 
practically there is little clashing between the State maritime 
quarantines; and that, while the national government could 
readily and effectively conduct all the more important quaran- 
tines upon the coast, to establish or maintain the very numerous 
smaller ones would be an excess of responsibility and labor. 
Moreover, it would seem that the people of each section are 
best qualified to judge of measures of protection required by 
their own peculiar surroundings ; and if they were not it might 
still be a questionable public policy to relieve the State govern- 
ments of this sanitary responsibility, and encourage thus a weak 
leaning upon the national government. But another view of 
the matter is had from the stand-point of the interior States. 
The interior States are as much interested in the efficiency of 
quarantine at New York or Xew Orleans as are the cities 
named, for fomites failing of proper disinfection at these points 
are rapidly carried to innumerable localities in the interior. 
Thus, in a measure, the people of the whole interior are de- 
pendent upon these quarantines, that is to say, upon the legis- 
lative liberality of the States in question, and the efficiency of 
their executive officers. 

Should, however, there be a persistently lax maritime 
quarantine on the part of a State, the interior States could 
maintain inland quarantine against the off'ending one, and by 
thus restricting its commerce compel a greater efficiency. 
Should an epidemic disease obtain lodgment in a State the 
others may, and frequently do, quarantine against it. In the 
Southern States particularly the interruption to interstate com- 
merce has been frequent by reason of quarantines. The effect 
of this has been beneficial in that it has stimulated the health 
authorities in their efforts to exclude epidemic disease. But if 
there is danger of the spread of cholera, yellow^ fever, small- 



410 TEXT-BOOK OF HYGIENE. 

pox, or plague from one State to another, the national author- 
ities, by virtue of the interstate quarantine act, may adopt the 
necessary preventive measures. 

The relation Avhich the national government has always 
borne toward the States in the matter of quarantine is that of a 
powerful ally, in the absence of local quarantine assuming 
jurisdiction, giving aid, when requested, to weak quarantines, 
and establishing quarantines at points, as the Delaware Break- 
water and Cape Charles, where one establishment serves for the 
protection of several States. All national quarantines have been 
located by the request or ready assent of the States in proximity. 

While it has been urged that quarantine is a function of 
the general government by reason of the constitutional right 
of Congress to regulate commerce, the other theory has pre- 
vailed, viz., that it is a police power appertaining to the State. 
The first quarantine laws were enacted by the States or colonies, 
by Massachusetts, for example, as early as 1648. 

A resolution looking to the national control of quarantine 
was ofiered in the Fourth Congress, April 28, 1796, as follows: 
" Resolved^ That the President of the United States be authorized 
to direct such quarantines to be performed on all vessels from 
foreign countries arriving at the ports of the United States as 
he shall judge necessary." This resolution failed to pass, but 
one was adopted authorizing the President " to direct the revenue 
officers and the ofiicers commanding ports and revenue-cutters 
to aid in the execution of quarantine laws, and also in the 
execution of the health laws of the States respectively, in such 
manner as may to him appear necessary." From that time 
until the passage of the interstate quarantine act of 1890, there 
was no national quarantine legislation that was not distinctively 
and only in aid of State laws. 

With regard to quarantine fees, however, without which 
many State and local quarantines could not be maintained, it is 
noticeable that Congress, while not forbidding their exaction, de- 
clares, in Section 4792 of the Revised Statutes, that " nothing in 



UNITED STATES QUARANTINE LATTS AND REGULATIONS. 411 

this Title shall enable any State to collect a duty of tonnage or 
impost without the consent of Congress." The inference is 
that Congress, in its constitutional power to regulate commerce, 
is unwilling to formally surrender this right. 

The right of the State to impose fees has been affirmed, 
however, by the Supreme Court of the United States. 

Before extending quarantine aid to a State it is the custom 
of the government to obtain a formal request from the Governor 
or State sanitary authorities. The agent of the government is 
the Surgeon-General of the Marine-Hospital Service, who 
assumes then the direction of expenditures and measures. 
When necessary the employes, sanitary guards, etc., of the 
Marine-Hospital Service are given a proper legal footing by 
being sworn in as State or local officers, deputy sheriffs, etc., 
and likewise under the law State officers may be endowed with 
the authority of United States sanitary officers. In this manner 
the national and State authorities work together harmoniously. 
Following are the United States quarantine laws in full : — 

UNITED STATES QUARANTINE LAWS AND REGULATIONS. 

Section 4792, Revised Statutes of the United States. 
The quarantines and other restraints established by the health laws 
of any State, respecting any vessels arriving in, or bound to, any port or 
district thereof, shall be duly observed by the officers of the customs 
revenue of the United States, by the masters and crews of the several 
revenue-cutters, and by the military officers commanding in any fort or 
station upon the sea-coast ; and all such officers of the United States 
shall faithfully aid in the execution of such quarantines and health laws, 
according to their respective powers and within their respective precincts, 
and as they shall be directed, from time to time, by the Secretary of the 
Treasury. But nothing in this Title shall enable smy State to collect a 
duty of tonnage or impost without the consent of Congress. 

national quarantine act. 

AN ACT to prevent tlie introduction of contagious or infectious diseases into the 

United States. 
Be it enacted by the Senate and House of Representatives of the 
United States of America, in Congress assembled, That no vessel or 
vehicle coming from any foreign port or country where any contagious 



412 TEXT-BOOK OF HYGIENE. 

or infections disease may exist, and no vessel or vehicle convening any 
person or persons, merchandise, or animals infected with any infectious 
or contagious disease, shall enter any port of the United States, or pass 
the boundary-line between the United States and ^ny foreign country, 
contrary to the quarantine laws of any one of said United States, into 
or through the jurisdiction of which said vessel or vehicle may pass, or 
to which it is destined, or except in the manner and subject to the regula- 
tions to be prescribed, as hereinafter provided. 

Sec. 2. That whenever any infectious or contagious disease shall 
appear in any foreign port or country, and whenever any vessel shall 
leave any infected foreign port, or, having on board goods or passengers 
coming from any place or district infected with cholera or yellow fever, 
shall leave any foreign port, bound for any port in the United States, the 
consular officer, or other representative of the United States at or nearest 
such foreign port shall immediately give information thereof to the 
Supervising Surgeon-General of the Marine-Hospital Service, and shall 
report to him the name, the date of departure, and the port of destination 
of such vessel ; and shall also make the same report to the health officer 
of the port of destination in the United States, and the consular officers 
of the United States shall make weekly reports to him of the sanitary 
condition of the ports at which they are respectively stationed ; and the 
said Surgeon-General of the Marine-Hospital Service shall, under the 
direction of the Secretary of the Treasur}^ be charged with the execu- 
tion of the provisions of this act, and shall frame all needful rules and 
regulations for that purpose, which rules and regulations shall be subject 
to the approval of the President, but such rules and regulations shall not 
conflict with or impair any sanitary or quarantine laws or regulations of 
any State or municipal authorities now existing, or which may hereafter 
be enacted. 

Sec. 3. That it shall be the duty of the medical officers of the 
Marine-Hospital Service and of customs officers to aid in the enforce- 
ment of the national quarantine rules and regulations established under 
the preceding section ; but no additional compensation shall be allowed 
said officers by reason of such services as they may be required to per- 
form under this act, except actual and necessary traveling expenses. 

Sec. 4. That the Surgeon-General of the Marine-Hospital Service 
shall, upon receipt of information of the departure of any vessel, goods, 
or passengers from infected places to an}'' port in the United States, 
immediately notify the proper State or municipal and United States 
officer or officers at the threatened port of destination of the vessel, and 
shall prepare and transmit to the medical officers of the Marine-Hospital 
Service, to collectors of customs, and to the State and municipal health 



UNITED STATES QUARANTINE LAWS AND REGULATIONS. 413 

authorities of the United States weekly abstracts of the consular sani- 
tary reports and other pertinent information received b}' him. 

Sec. 5. That whenever, at any port of the United States, any State 
or municipal quarantine sj-stem may now or may hereafter exist, the offi- 
cers or agents of such system shall, upon the application of the respective 
State or municipal authorities, be authorized and empowered to act as 
officers or agents of the national quarantine S3'stem, and shall be clothed 
with all the powers of United States officers for quarantine purposes, 
but shall receive no pay or emolument from the United States. At all 
other ports where, in the opinion of the Secretary of the Treasury, it 
shall be deemed necessary to establish quarantine, the medical officers or 
other agents of the Marine-Hospital Service shall perform such duties in 
the enforcement of the quarantine rules and regulations as may be 
assigned them by the Surgeon-General of that Service under this act : 
Provided^ That there shall be no interference in any manner with any 
quarantine laws or regulations as they now exist, or may hereafter be 
adopted under State laws. 

Sec. 6. That all acts or parts of acts inconsistent with this act be, 
and the same are hereby, repealed. 

Approved April 29, 18T8. 

[Extract from Quarantine Act of August 1, 1888.] 
AN ACT to perfect the quarantine service of the United States. 

Be it enacted by the Senate and House of Representatives of the 
United States of America, in Congress assembled, That whenever any 
person shall trespass upon the grounds belonging to any quarantine 
reservation, or whenever any person, master, pilot, or owner of a vessel 
entering any port of the United States, shall so enter in violation of 
Section 1 of the act entitled, "An act to prevent the introduction of 
contagious or infectious diseases into the United States," approved April 
twenty-ninth, eighteen hundred and seventy-eight, or in violation of the 
quarantine regulations framed under said act, such person, trespassing, 
or such master, pilot, or other person in command of a vessel shall, upon 
conviction thereof, pay a fine of not more than three hundred dollars, or 
be sentenced to imprisonment for a period of not more than thirty days, 
or shall be punished by both fine and imprisonment, at the discretion of 
the court. And it shall be the duty of the United States attorney in 
the district where the misdemeanor shall have been committed to take 
immediate cognizance of the offense, upon report made to him by any 
medical officer of the Marine-Hospital Service, or by any officer of the 
Customs Service, or by any State officer acting under authority of 
Section 5 of said act. 



414 TEXT-BOOK OF HYGIENE. 

Sec. 2. That as soon after the passage of this act as practicable, the 
Secretary of the Treasury shall cause to be established, in addition to 
the quarantine established by the act approved March fifth, eighteen 
hundred and eighty-eight, quarantine stations, as follows : One at the 
mouth of the Delaware Bay ; one near Cape Charles, at the entrance of 
the Chesapeake Bay; one on the Georgia coast; one at or near Key 
West ; one in San Diego Harbor ; one in San Francisco Harbor ; and one 
at or near Port Townsend, at the entrance to Puget Sound ; and the said 
quarantine stations when so established shall be conducted by the 
Marine-Hospital Service under regulations framed in accordance with the 
act of April twenty-ninth, eighteen hundred and seventy-eight. 

Approved August 1, 1888. 

AN ACT to prevent the introduction of contagious diseases from one State to another and 
for the punishment of certain offenses. 

Be it enacted by the Senate and House of Representatives of the United 
States of America in Congress assembled^ That whenever it shall be made 
to appear to the satisfaction of the President that cholera, yellow fever, 
small-pox, or plague exists in any State or Territor}^, or in the District 
of Columbia, and that there is danger of the spread of such disease into 
other States, Territories, or the District of Columbia, he is hereby author- 
ized to cause the Secretary of the Treasur}^ to promulgate such rules 
and regulations as in his judgment may be necessary to prevent the 
spread of such disease from one State or Territor}^ into another, or from 
any State or Territory into the District of Columbia, or from the District 
of Columbia into any State or Territory, and to employ such inspectors 
and other persons as may be necessary to execute such regulations to 
prevent the spread of such disease. The said rules and regulations shall 
be prepared by the Supervising Surgeon-General of the Marine-Hospital 
Service, under the direction of the Secretary of the Treasury. And any 
person who shall willfully violate any rule or regulation so made and 
promulgated shall be deemed guilty of a misdemeanor, and upon convic- 
tion shall be punished by a fine of not more than five hundred dollars, 
or imprisonment for not more than two years, or both, in the discretion 
of the court. 

Sec. 2. That any officer, or person acting as an officer, or agent of 
the United States at any quarantine station, or other person emplo3'ed to 
aid in preventing the spread of such disease, who shall willfully violate 
any of the quarantine laws of the United States, or an3^ of the rules and 
regulations made and promulgated by the Secretary of the Treasury as 
provided for in Section 1 of this act, or any lawful order of his superior 



UNITED STATES QUARANTINE LAWS AND REGULATIONS. 415 

officer or officers, shall be deemed guilt}' of a misdemeanor, and upon 
conviction shall be punished by a fine of not more than three hundred 
dollars, or imprisonment for not more than one 3'ear, or both, in the dis- 
cretion of the court. 

Sec. 3. That when any common carrier or officer, agent, or employe 
of an}- common carrier shall willfully violate any of the quarantine laws 
of the United States, or the rules and regulations made and promulgated 
as provided for in Section 1 of this act, such common carrier, officer, 
agent, or employe shall be deemed guilty of a misdemeanor, and shall, 
upon conviction, be punished by a fine of not more than five hundred 
dollars, or imprisonment for not more than two years, or both, in the dis- 
cretion of the court. 

Approved March 28, 1890. 



NDEX. 



Absolute and relative humidity, 6 
Actinomycosis, 343 
Adjustable school-desk, 197 
Adulterations in milk, 91 

of flour, 107 
"A. G-. M." water-closet, 170 
Aids to ciuarantine, 392 
Air-currents and their influence upon 

health, 18 
Alcohol poisoning, 112 
Alcoholic beverages, 111 
Alkaloidal beverages, 117 
Alum as a purifier of muddy water, 59 
Ammonia in water, 74 
Angus Smith's experiments on carbon j 

dioxide and organic matter, 27 
Aniline poisoning, 220 
Animal diseases and ground-water, 183 
Anthrax, 345 

Antiseptics and antisepsis, 347 
Arsenic in wall-papers, 163 

poisoning, 225 
Atmosphere, composition and physical 
conditions of, 2 

its influence upon health, 1 

its limit upward, 3 
Atmospheric pressure and health, 8 

Bacillus anthracis as a cause of diseased 

meat, 103 
Bacillus of anthrax, 345 
of glanders, 345 
of typhoid fever, 329 
Bacteria in the atmosphere, 32 
Bacteriological examination of drinking- 
water, 77 
Baker, H. B., on effects of low tempera- 
ture on health, 15 
Barometric pressure, 3 
Barracks, 234 
Bathing, dangers of, 270 

rules for, ^269 
Baths and bathins:, 267 
Beer, 116 

Berlier's system, 144 
Bert's observations on diminished at- 
mospheric pressure, 10 
Birth-rates, 363 
Black death, 294 

hole of Calcutta, 28 

27 



Boccaccio on the plague, 294 

Bora, 19 

Boudin on malarial fever from drinking- 
water, 60 

Bovine tuberculosis, 344 

Bowditch, H. I,, on soil moisture and 
consumption, 131 

Brandy, 114 

"Brass-founders' ague," 219 

Bread, 106 

Broad Street pump epidemic of cholera, 
64 

Buchanan, Dr. G., on earth-closets, 142 
on soil moisture and consumption, 
133 

Burial-o;rounds, supposed dangers of, 
280 

Bury ventilator, 161 

Butter, 95 

Cabiadis on the plague in Bagdad, 297 
Cable, G-. W., on convict-lease system, 

257 
Caisson disease, 12 
Camp diseases, 236 

Perry, 397 
Camps of probation, 396 
Carbon-bisulphide poisoning, 215 
Carbon dioxide in atmosphere, 2, 26 

poisoning, 214 
Carbon monoxide in air, 29 

poisoning, 213 
Caterham epidemic of typhoid fever, 61 
Cerebro-spinal meningitis, 339 
Chamberland's filter, 69 
Chambers, J. W., on pollution of hy- 
drant-water, 66 
Chantemesse and Yidal on the bacillus 
typhoideus in drinking-water, 63 
Cheese, 96 

Chemical composition of ground-air, 123 
Chlorides in water, 72 
Chlorine-gas poisoning, 212 
Chocolate, 118 
"Choke-damp," 214 
Cholera and drinking-water, 321 

and ground-water, 130 

Asiatica, 314 

bacillus, 319 

causation of, 320 

(417) 



418 



INDEX. 



Cholera from infected water, 64 

prevention of, 323 

special quarantine measures against, 
389 
Cider, 115 

Cisterns as storage reservoirs, 47 
Civilian camps, 240 
Classification of drinking-waters, 78 
Clothing, absorption of heat by, 275 

how to render non-inflammable, 278 

materials, 275 

of the soldier, 233 
Coal-gas, 30 
Coffee, 117 
Condiments, 108 
Connolly trap, 176 

Consumption among school-children, 
204 

and soil moisture, 131 
Contagion and infection, 289 
Contagious diseases and schools, 204 
Contagium animatum, 285 
Contamination of hydrant-water, 66 
Cowles, Dr. E., experiments on heating 

hospitals, 184 
Creamometer, 94 
Cremation, 282 

of sewage and garbage, 150 
Cucumber odor in drinking-water, 52 
Cultivation of bacteria, 288 
Cysticercus in meat, 100 

Da Costa, Dr. J. M., on irritable heart, 
264 

Daily allowance of water in American 
cities, 46 

Dead, disposal of, 279 

Death-rate and birth-rate, 361 

Decayed meat and fish as causes of dis- 
ease, 100 

"Dececo" closet, 171 

DeChaumont's rale regarding ground- 
water oscillations, 130 

Defective hearing among school-chil- 
dren, 202 

Defoe, on the plague, 295 

Dengue, 336 

Deodorizers, 348 

Diarrhoea and dysentery in armies, 236 

Dickson, on the plague in India, 297 

Digestive derangements among school- 
children, 203 

Diphtheria, 335 

Diseases caused by high temperature, 14 
from impure water, 58 
from infected and spoiled meat, 99 
from infected milk, 92 
from soil impurities, 129 
on shipboard, 252 

Disinfectants and disinfection, 347 

Disinfection, methods of, 353 



Distilled water, 54 
Drainage of wet soils, 133 
Drowned persons, restoration of, 270 
Duration of infection, 291 
Dwellings and overcrowding, 151 

materials of which to be built, 158 

Earth-closets, 141 

Eberth's bacillus as a cause of typhoid 

fever, 63 
Eggs as food, 105 
Electric light and its dangers, 165 
Emmerich on the innocuousness of im- 
pure water, 61 
Entombment, 281 
Epidemic diseases, 290 

due to defective ventilation, 29 
Erismaun on Liernur's system, 143 
Exercise and training, 261 

physiological effects of, 261 

Filtration of water, 69 

"Fire-damp," 30, 214 

Flushing cistern for water-closets, 173 

Fodor, on the production of carbon di- 
oxide, 27 

Pohn, 19 

Folsom, C. F., on typhoid fever from 
infected water, 63 

Food necessary to health, 81 
of the soldier, 232 

Forwood, Dr. W. S., on hydrochloric- 
acid fumes, 212 

Freire, on yellow-fever germ in soil, 125 

Fresh-air inlet, 177 

Gardner, James T., on Rochdale sys- 
tem, 139 
Gas poisoning, 29 
Germ theory, 285 
Gihon, Dr. A. L , on naval hygiene, 243 

on syphilis in the United States, 342 
Gin, 115 
Glanders, 345 
Green vegetables, 108 
Ground-air, 122 
Ground-water, 127 

and cholera, 130 

and typhoid fever, 131 

Habitations, 151 

Hammond's experiment on organic mat- 
ter in the air, 28 

Hardness of water, 56 

Harmattan, 19 

Heart disease and altitude, 11 

Heating and ventilation of dwellings, 
160 

Hecker on the plague, 294 

Holt, Dr. Jos., on Louisiana quarantine, 
374 



INDEX. 



419 



Hopper-closets, 169 

Hospital administration and manage- 
ment, 187 

records, 189 
Hospitals, 179 
House-drainage, 166 
Howard, John, on hospital construction, 

183 
Humidity and health, 18 

of the atmosphere, 5 
Hydrophobia, 34-4 

Illuminating gas, dangers of, 164 
Impurities in water, 55 
Increased atmospheric pressure, 12 
Incubation of infectious diseases, table 

of, 291 
Industrial hygiene; 207 
Influence of barometric pressure upon 

results of operations, 12 
Influenza, 338 
Inland quarantine, 393 
Inoculation of small-pox, 303 
Interment, 279 
in war, 282 
Iodine poisoning, 216 

Jenner, Edward, and vaccination, 306 
Jesty, Benjamin, 306 
Johns Hopkins Hospital, 180 
Jones, Dr. Joseph, on syphilis among 
the mound-builders, 341 

Kefyr, 116 

Kober, G. M., on mountain fever, 49 

Koch, R., on the cholera spirillum in 

drinking-water, 65 
Kumys, 116 

Lakes and ponds as sources of drinking- 
water, 51 

Lambrecht's polymeter, 8 

Lead poisoning, 217 

Legumes, 107 

Liernur's pneumatic system, 143 

Lighting of dwellings, 163 

Lortet's observations on diminished at- 
mospheric pressure, 8 

Louisiana quarantine, 371 

Low temperature as a cause of respira- 
tory diseases, 15 

Malarial fevers in armies, 237 
Marine hygiene, 243 
Maritime quarantine, 367 
administration of, 380 
Marsh-water and malaria, 59 
Marshall, John, on cholera from infected 

water, 64 
Maryland Maternite case-record, 189 
Mate, 119 



McClellan's trap, 174 
McSherr3^ R., on siguatera, 102 
Measles, 334 
Meat, 97 

extracts and essences, 99 
Mercurial poisoning, 218 
Metabolism during muscular exercise, 88 
Methods of cooking, 109 

of sewage removal, 136 
Michigan method of restoring the appa- 
rently drowned, 271 
Midden privies, 138 
Military and camp hygiene, 231 
Milk as food, 89 

sickness, 94 
Mineral poisons in water, 75 
Mistral, 18 
Montaaue, Lady M. "W., on inoculation, 

303 
Montgomery quarantine conference, 405 
Moore, J. W., on seasonal prevalence 

of pneumonia, 17 
Morin, on fresh air required in occupied 

apartments, 40 
Mortality in prisons, 257 
Motion of the atmosphere, 7 
Mountain fever, 49 

sickness, 10 
Myopia of school-children, 199 

National quarantines, 368 
Blackbeard Island, 387 
Chandeleur Island, 385 
Delaware Breakwater, 388 
stations, regulations for, 380 

Naval hygiene,"243 
rations, 251 

Neirnsee, J. R , on ventilating hospital 
wards, 184 

Nervous disorders among school-chil- 
dren, 203 

New York quarantine, 370 

Nichols, A. H., on pollution of drinking 
water, 52 

Nitrates and nitrites in water, 73 

Norther, 19 

Occupation neuroses, 229 
Occupations, hygiene of, 207 
Organic matter in water, 71 
Organisms in small -pox, 302 
Ortental plague, 293 
Over Darwen epidemic of drinking- 
water, 62 
Overexertion, 264 

Oxygen and COg in ground-air, 124 
Oxygen in atmospheric air, 3 
Ozone in the atmosphere, 7 

Pan-closets, 167 

Passengers on shipboard, 246 



420 



INDEX. 



Pathogenic organisms in ground-air, 124 
Pavilion liospitals, 18 
Pebrine, 286 

Pengra, C. P., on bacteria in drinking- 
water, 53 
Pensacola quarantine regulations, 383 
Pepper, William, on consumption and 

soil moisture, 182 
Perlsucht, 344 

Peroxide of hydrogen in the atmos- 
phere, 7 
Petroleum vapor as a poison, 217 
Pettenkofer, on ground- air, 123 

on ground-water and cholera, 322 
Phosphorus necrosis, 226 
Phthisis in armies, 238 
Physical training, 262 
Physiological action of alcohol, 111 
Plague, 293 
Plunger-closets, 168 

Plymouth epidemic of typhoid fever, 63 
Pneumonia and cold weather, 16 
Poisonous dust, 221 

gases and vapors, 211 
Power, W. H., on scarlet fever from 

milk, 93 
Preventive inoculation, 287 
Prison hygiene, 255 

punishments, 258 
Privies, deodorization of contents of, 
137 

removal of contents of, 137 

ventilation of, 137 
Privy-vaults, construction of, 136 

pits, 138 

system, 136 

wells, 138 
Procopius, on the plague, 293 
Prudden, on typhoid bacilli in drinking- 
water, 53 
Ptomaines in meat, 101 
Public baths, 273 
Purification of drinking-water, 68 
Purulent conjunctivitis, 238 

Quarantinable diseases, 366 
Quarantine, 365 

aids, 392 

conference at Montgomery, 405 

contrivances, 377 

correlation of national, State, and 
municipal laws, 407 

laws of United States, 411 

practice, 384 

regulations, Pensacola, 383 
Texas, 382 

Rabies, 344 

Rag-sorters' disease, 224 
Railroad inspection against small-pox, 
404 



Railroad inspection against yellow 
fever, 402 

quarantine, 400 
Registration of births, 360 

of deaths, 359 

of diseases, 361 

of marriages, 360 
Relapsing fever, 327 
Renuie, on the plague, 297 
Restoration of apparently drowned per- 
sons, 270 
River- water, 48 
Rochdale system, 139 
Roy, A., on carbon-dioxide poisoning, 

214 
Rum, 115 

Sailor-life, 243 

Salomon, Dr. L. F., on sulphur disin- 
fection, 379 
Sanitary cordon, 393 
Sausage poisoning, 101 
Scarlet fever, 334 

from milk, 93 
Schlagintweit's observations on moun- 
tain sickness, 9 
Schone system, 144 
School furniture, 196 

house construction, 193 

life, diseases of, 199 
Scurvy in armies, 238 
Sea-bathing, 268 

Season and mortality from various dis- 
eases, 20 
Seaton and Buchanan, on protective 

power of vaccination, 309 
Self-purification of flowing water, 50 
Separate system, 144 
Sewage and sewerage, 135 

farms, 149 

final disposal of, 149 

irrigation at Pullman, 149 
Sewer-air, 30 
Sheep-pock, 343 
Ship sanitation, 246 
Simoon, 19 
Sirocco, 19 

Site for dwellings, 153 
Small-pox, 299 
Smart, C, on mountain fever, 49 

on pollution of cistern-water, 47 
Soap test for hardness in water, 56 
Soil atmosphere, 122 
Soil, character of, for building-sites, 154 

its physical and chemical charac- 
ters, 121 

moisture and health, 153 

pipe, 175 
Sources of drinking-water, 47 
Spinal curvature in school-children, 203 
Spirillum of relapsing fever, 328 



INDEX. 



421 



Splenic fever, 286 

Spongilla fluviatilis, 52 

Spring-water, 53 

Standards of purity of drinking-water, 

55 
Steam disinfecting-eliamber, 379 
Sternberg, G. 31., on destruction of 

patliogenic germs by boiling 

water, 68 
on yellow-fever germs of Freire, 

125 
Storage of water, 47 
Study hours for pupils, 198 
Suicide and season, 26 
Sun-stroke and humidity, 13 
Supervision of sanitary arrangements, 

177 
Sweating sickness, 298 
Swell-head, 343 
Swill-milk, 93. 
Syphilis, 340 

Table of constituents of animal foods, 
84 

of constituents of ve2:etable foods, 
85 
Tea, 118 
Temperature and health, 13 

of the air, 5 

of fire-rooms of ships, 250 
Tents and huts, 235 
Tests for atmospheric impurities, 33 

for impurities in drinking-water, 70 
Texas quarantine regulations, 382 
Thome on typhoid fever from drinking- 
water, 61 
Tobacco, 119 

Toilet's system of barracks, 234 
Total solids in water, 71 
Tracy, Dr. R. S., on infecundity of 

tobacco-workers, 223 
Traps, 173 

Trichina spiralis in meat, 99 
Tuberculous meat, 104 
Typhoid fever, 328 



Tj^phoid fever and ground-water, 131 

causation of, 329 

from drinking-water, 61 

in armies, 238 
Typhus fever, 330 

in armies, 238 
Tyrotoxicon in milk, 95 

Vaccination, 305 

and syphilis, 311 

mode of performing the operation, 
309 
Valve-closets, 168 

Vaughan, V. C, on the bacillus ty- 
phoideus in drinking-water, 64 

on poisonous cheese, 97 

on tyrotoxicon as a cause of cholera 
infantum, 95 
Vaughan's daily ration, 83 
Venereal diseases in armies, 239 
Ventilation, 38 

and heating of hospitals, 183 

of prisons, 258 

of ships. 248 
Vital statistics, 359 
Voit's standard diet-tables, 83 

Waring system at Memphis, 145 

Water-carriage system of sewage re- 
moval, 144 

Water-closets, 167 

Water required by human beings, 45 
supply in dwellings, 166 

Well-water, 53 

Whisky, 114 

Wilkinson, Dr.C. P., on Louisiana quar- 
antine, 372 

Wines, 115 

Wolpert's air-tester, 34 

Wyman's case-record, 189 

Yellow fever, 331 

causation of, 332 
Yellow-fever cordon in Texas, 395 



MARCH, 1890. 



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OF THE 



Medical Publications 

OF 

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NEW BOOKS IN PRESS AND IN PREPARATION, 



BACTERIOLOGICAL DIAGNOSIS— TABULAR AIDS FOR USE IN 
PRACTICAL WORK. By Jamps Eisenbehg, Ph.D., M.D.. Vienna. Tians- 
lated and augmented, with the permission of the author, from the Second German 
Edition, by Norval II. Pierce, M.D., Surgeon to the Out-Door Department of 
Michael Reese Hospital; Assistant to Surgical Clinic College of Physicians and Sur- 
geons, Chicago, 111. In one Octavo volume. In Press. 

LECTURES ON ARTISTIC ANATOMY AND THE SCIENCES USE- 
FUL TO THE ARTIST. A series delivered at the Art Institute, Chicago, by 
S. V. Clevenger, M.D., Consulting Physician. Reese and Alexian Hospitals ; Member 
numerous American Scientific and Medical Societies; Author of "Spinal Concussion," 
"Comparative Physiology and Psychology," etc. Illustrated with Seventeen (17) 
fine full-page Lithographic Plates. In one handsome Quarto volume. lu Press. 

TWELVE LECTURES ON THE STRUCTURE OP THE CENTRAL 
NERVOUS SYSTEM. For Physicians and Students. By Dr. Ludwig 
Edinqer, Frankfort-on-the-Main. Second Revised Edition, with 133 Illustrations. 
Translated by Willis Hall Vittum, M.D., St. Paul, Minn. Edited by C. Eugkne 
RiGGS, A.M., M.D., Professor of Mental and Nervous Diseases, University of Minne- 
sota; Member of the American Neurological Association. In one Octavo volume. 
In Press. 

THE PRINCIPLES OP SURGERY. For Students and Practitioners. By N. 
Senn, M.D., Ph.D., Attending Surgeon Milwaukee Hospital ; Professor of Principles 
of Surgery in Rush Medical College, Chicago, 111., etc. In one Octavo volume. 
Illustrated. In Preparation. 

DISEASES OP THE HEART, LUNGS, AND KIDNEYS. By N. < 
Davis, Jr., A.M., M.D., Professor of Principles and Practice of Medicine in ili*- 
Chicago Medical College, Chicago, 111., etc. In one neat 12mo volume. No. o in thi^ 
" Physicians' and Students' Ready-Reference Series." In Preparation. 

CHILDBED: ITS MANAGEMENT: DISEASES AND THEIR TREAT- 
MENT. By Walter P. Manton, M.D., Visiting Physician to ;the Detroit 
Woman's Hospital; Consulting Gynsecologist to the Eastern Michigan Asylum; 
President of the Detroit Gynsecological Society ; Fellow of the American Society of 
Obstetricians and Gynascologists, and of the British Gynsecological Society ; Member 
of the Michigan State Medical Society, etc. In one neat 12mo volume. No. 6 in 
the " Physicians' and Students' Ready-Reference Series." In Preparation. 

Arrangements are being made for volumes upon the "Bye," "Nose and 
Throat," " Gynaecology, " " Medical Microscopy," "Physiology," ct,., 
to follow the above, at intervals, in the " Physicians' and Students' Ready-Reference 
Series." 

The Physicians' and Students' Ready- Reference Series 

Includes publications of great value to students during their attendance at college, and 
to the busy physician in his daily practice. While they in no way attempt to supplant 
the various Text-Books, it cannot he doubted that they are necessary to the often overworked 
student when examination' time is approaching, previous to which, for weeks, but little 
time can be gained from the lectures in which to make careful and thorough pre])aration 
for the examination-room. 

Complete synopses of the several important branches, and valuable monographs on 
various important subjects, are furnished in the publications of this series in such form 
and arrangement by competent writers as to render them of special }'raotioal value to the 
busy student and also to the physician in active practice. The volumes are neat and con- 
venient in size and shape, and appropriately illustrated with many fine wood-engravings. 

See Pages 3, 20, 21, and 27 for those now published, and the 
upper part of this page for those in preparation. 

2 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



JUST PUBLISHED -A NEW AND VALUABLE WORK OTVI 

Practical Electricity 

MEDICINE AND SURGERY. 



G. A. LIEBIG, Jr., Ph.D., 

Assistant in Electricity, Johns Hopkins University ; Lecturer on Medical Electricity, College of Phy- 
sicians and Surgeons, Baltimore; Member of the American Institute 
of Electrical Engineers, etc., 

—AND- 

GEORGE H. ROHE, M.D., 

Professor of Obstetrics and Hygiene, College of Physicians and Surgeons, Baltimore; Visiting Physician 

to Bay View and City Hospitals; l^irector of the Maryland Maternite: Associate 

Edito>- "Annual of the Universal Medical Sciences," etc. 

PROFUSELY ILLUSTRATED BY WOOD-ENGRAVINGS AND ORIGINAL DIAGRAMS, AND PUBLISHED IN ONE 

HANDSOME ROYAL OCTAVO VOLUME OF ABOUT 400 PAGES, BOUND IN EXTRA CLOTH. 
NET PRICE, UNITED STATES and CANADA, $2.00, Post-paid; GREAT BRITAIN, 8s. 6d. ; FRANCE, 12 fr. 40. 



The part on Physical Electricity, written by Dr. Liebig, one of the recognized 
;rathoiitie6 on the science in the United States, treats lully such topics of interest as 
"Storage Batteries. Dynamos, the Electric Light, and the Principles and Practice of 
Electrical Measurement in their relations to Medical Practice. 

Professor Pvohe, who writes on Electro-Therapeutics, discusses at length the recent 
developments of Electricity in the treatment of stricture, enlarged prostate, uterine 
libroids. pelvic cellulitis, and other diseases of the male and female genito-urinary organs. 

The applications of Electricit}^ in dermatology, as well as in the diseases of the 
nervous system, are also fully considered. 



THE SECOND VOLUME IN THE PHYSICIANS' AND STUDENTS' 
READY REFERENCE SERIES. 



h:jPln:d-book: 

Materia MediGaJtiapniaeji, and Ttierapeuties 

By OUTHBERT BQ-WEN, M.D., B.A., 

Editor of " Notes on Practice." 



KXTKACT FROM THE PREFACE '« While this is essentially a Student's MaxNual, alarge 

amount of matter has been incorporated which, it is hoped, will render it a useful reference-book to the young 
GRADUATE who is just entering on his professional career, and more particularly the individual whose sphere 
of work demands a more practical acquaintance with pharmaceutical processes than is required of the ordi- 
nary city practitioner. Great care has been taken throughout the book to familiarize the student with the 
best methods of administering the various drugs he \f\\\ be called upon to use, and with this object a large 
number of standard prescriptions have been selected from the works of the most eminent authorities, which 
he can either adopt, with modifications to suit particular cases, or use as models on which to construct his own 
formula;." 

This excellent manual comprises in its 366 small criticism we can make on this volume is that it does 
octavo pages about as much sound and valuable in- not claim enough. — Southern California Prac- 
Ibrmation on the subjects indicated in its title as titioner. 

could well be crowded into the compass. The book The book is one of the very best of its class. — 

is exhaustively and correctly indexed, and of a con- , Cohi^nbus Medical yournal. 

venien: form. The paper, press-work, and binding ' This is a verj' condensed and valuable 7-esiime 

are excellent, and the typography {long primer and of the drugs recognized by the United States Phar- 
brevier) is highly to be commended, as opposed to \ macopceia, and all the officinal and important 
the nonpareil and agate usually used incompendsof preparations. — SontJieryi Medical Record. 
this sort, and which are destructive to vision and j Dr. Bowen's work is a very valuable one indeed, 
temperalike. — St. Louis Med. and Surg. Joiir. \ and will be found " to fill a want " beyond a doubt. 

In going through it, we have been favorably im- j! — Cinciniiati Medical News. 
pressed by the plain and practical suggestions in j It is short and concise in its treatment of the 
regard to prescription writing, and the metric sys- j subjects, yet it gives sufficient to gain a very correct 
tern, and the other things which must be known in ,i knowledge of everything that comes under this head- 
order to write good and accurate prescriptions. — ' 1 ing. This is a ready work for the country physician, 
Medical and Surgical Reporter. \ who must of necessity have a more practical acquain- 

M any works claim more in their title-pages than tance with pharmaceutical processes. — Medicac 
can be verified fvurther on, but the only adverse Brie/. 



One 12ino voluirie of 370 pages. Handsomely Bound in Dark-Blae Cloth. 

Price, post-paid, in the United States and Canada, $1.40, net: 

in Great Britain, 6s. 6d.; in France, 9 fr. 25. 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



Bashore's Improved Clinical Chart. 

For the SEPARATE PLOTTINa of TEMPEEATUEE, PULSE, and EESPIEATION. 

Designed for the Convenient, Accurate, and Permanent Daily Recording of Cases in 
Hospital and Private Practice. 

By HARYHY B. BASHORH, m.D. 



1 




COPTRIGHTED, 1888, BY F. A. DAVIS. 

50 Oliaarts, in Ta-Tolet I^^oriara.. Size, S 2r 12 i3:i.clies. 



Price, in the United States and Canada, Post-paid, 60 Cents, 
Net ; Great Britain, 2s. 6d. ; France. 3 fr. 60. 



The above diagram is a little more than one-fifth (1-5) the actual size of the chart and shows the 
method of plotting, the upper curve being the Temperature, the middle the Pulse, and the lower the 
Respiration. By this method a full record of each can easily be kept with but one color ink. 

It is so arranged that all practitioners will find it an invaluable aid in the treatment of their patients. 

On the back of each chart will be found ample space conveniently arranged for recording "Clinical 
History and Symptoms" and "Treatment." 

By its use the physician will secure such a complete record of his cases as will enable him to review 
them at any time. Thus he will always have at hand a source of individual improvement and benefit in 
the practice of his profession, the value of which can hardly be overestimated. 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



-#BOOPC#- 



i>N 



The Phvsician Himself 



AND THIxVGS THAT CONCERN 



HIS REPUTATION AND SUCCESS 



D. W. CATHELL, M.D., 

BALTIMORE, MD. 

Being the NINTH EDITION (Enlarged and Thoroughly Revised) of the 'PHYSICIAN 

HIMSELF, AND WHAT HE SHOULD ADD TO HIS SCIENTIFIC ACQUIREMENTS 

IN ORDER TO SECURE SUCCESS.' 



la One Handsome Octavo Volume of 298 Pages, Bound in Extra ClotL 

Priee, Post-paid, in United States and Canada, $2.00, Net; Great 

Britain, 8s. 6d. ; France, 12 fr. 40. 



This remarkable book has passed through eight (8) editions in less 
tiian live years, has met with the unanimous and hearty approval of the 
Profession, and is practically indispensable to every young graduate 
Avho aims at success in his chosen profession. It has just undergone a 
thorough revision by the author, who has added much new matter cover- 
ing many points and elucidating man 3^ excellent ideas not included in 
former editions. This unique book, the only complete one of the kind 
ever written, will prove of inestimable pleasure and value to the practi- 
tioner of many 3-ears' standing, as well as to the young ph^'sician who 
needs just such a work to point the way to success. 

We give below a few of the many unsolicited letters received by 
the author, and extracts from reviews in the Medical Journals of the 
former editions : 



'•' 'The Physician Himself is an opportune and 
most useful book, which cannot fail to exert a good 
influence on the morale and the business success of 
the Medical profession." — From Prof. Roberts 
Bartholoio, Philadelphia, Pa. 

'•\ have read 'The Physician Himself with 
plea-sure — delight. It is brimful of medical and 
social philosophy' ; every doctor in the land can 
study it with pleasure and profit. I wish I could 
have read such a work thirty years ago." — From 
Prof, fohn S. Lynch, Baltimore, I^Id. 

" ' The Physician Himself interested me so 
much that I actually read it through at one sitting. 
It is brimful of the ver>' best advice possible for 
medical men. I, for one, shall try to profit by it." — 
From Prof. William Goodell, Philadelphia, 

" I would be glad if, in the true interest of the 
profession in 'Old England,' some able practitioner 
here would prepare a work for us on the same line as 
'The Physician Himself.'" — From Dr. Jukes de 
Sty rap, Shrezvsbury, Englaitd. 

" I am most favorably impressed with the 
wisdom and force of the points made in ' The Phy- 
sician Himself,' and believe tjie work in the hands 
of a young graduate will greatly enhance his chances 
for professional success. "—/^r<7w Prof. D. Hayes 
Agnettf, Philadelphia, Pa. 

" This book is evidently the production of an 
unspoiled mind and the fruit of a ripe career. 1 
admire its pure tone and feel the value of its practi- 
cal points. How I wish I could have read such a 
guide at the outset of my career!" — From Prof. 
James Ne^jins Hyde, Chicago, III. 

" It contains a great deal of good sense, well 
expressed." — Fro>nProf. Oliver Wendell Holmes, 
Harvard University. 



" 'The Physician Himself is useful alike to the 
tyro and the sage — the neophj-te and the veteran. It 
is a headlight in the splendor of whose beams a 
multitude of our profession shall find their way to 
success." — From Prof . J. M. Bodine, Dean Uni- 
versity of Louisville. 

" It is replete with good sense and sound phi- 
losophy. I^o man can read it without realizing that 
its author is a Christian, a gentleman, and a shrewd 
obserrer." — FrotnProf. Edward Warren (Bey), 
Chevalier of the Legion of Honor, etc., Paris, 
j France. 

i "I have read 'The Physician Himself,' care- 

' fully. I find it an admirable work, and shall advise 
\ our Janitor to keep a stock on hand in the book de- 
partment of Bellevue." — From Prof. William T. 
''■ Lusk, New York. 

j " It must impress all its readers with the belief 

I that it was written by an able and honest member of 

' the profession and for the good of the profession." — 

, Fro7n Prof. W. H. Byford, Chicago, III. 

j "It is marked with good common sense, and 

\ replete with excellent maxims and suggestions for 
I the guidance of medical men." — From The British 
Medical Journal, London. 

" We strongly advise every actual and intend- 
ing practitioner of medicine or surgerj^ to have 
' The Physician Himself,' and the more it influences 
! his future conduct the better he will be." — From 
i The Canada Medical and Surgical Journal, 

Montreal. 
\ "We would advise every doctor to well wa^gh 

' the advise given in this book, and govern his con> 
duct accordingly." — From The Virginia Medical 
^ Monthly. 



(F. A. DA¥IS, Medical Publisher, Philadelphia, Pa., U.S. A J 



AN IMPORTANT PUBLICATION OF GREAT VALUE TO THE MEDICAL 
AND LEGAL PROFESSIONS. 



Spinal Concussion: 

Surg-ically Considered as a Cause of Spinal Injury, and Neurolo^- 

cally Restricted to a Certain Symptom Group, for 

^which is Suggested the Designation 

ERICHSEN'S DISEASE, AS 0»E FORM OF THE TRAUMATIC NEDROSES. 



S. V. CLEVENGER, M.D., 

CONSULTING PHYSICIAN REESE AND ALEXIAN HOSPITALS; LATE PATHOLOGIST COUNTY INSANE ASYLUM, 
CHICAGO; MEMBER OF NUMEROUS AMERICAN SCIENTIFIC AND MEDICAL SOCIETIES; COLLABORATOR 
AMERICAN NATURALIST, ALIENIST AND NEUROLOGIST, JOURNAL OF NEUROLOGY" AND 
PSYCHIATRY, JOURNAL OF NERVOUS AND MENTAL DISEASES; AUTHOR OF "COM- 
PARATIVE PHY'SXOLOGY AND PSYCHOLOGY"," "ARTISTIC ANATOMY'," ETC. 



For more than twenty years this subject has occasioned bitter con- 
tention in law courts, between physicians as well as attorneys, and in 
that time no work has appeared that reviewed the entire field judicially 
until Dr. Clevenger's book was written. It is the outcome of five years' 
special stud}' and experience in legal circles, clinics, hospital and private 
practice, in addition to twenty years' labor as a scientific student, w^-iter. 
and teacher. 

The literature of Spinal Concussion has been increasing of hite years 
to an unwieldy shape for the general student, and Dr. Clevenger has in this 
work arranged and reviewed all that has been done by observers siiu-e 
the days of Eriehsen and those who preceded him. The diiierent and 
sometimes antagonistic views of many authors are fully given from the 
writings of Eriehsen. Page, Oppenheim, Erb. Westphal. Abercrombic\ 
Sir Astley Cooper, Boyer, Charcot, Leyden, Rigler. Spitzkn, Putnam. 
Knapp, Dana, and many other European and American students of the 
subject.* The small, but important, work of Oppenheim, of tlie Berlin 
University, is fully translated, and constitutes a chapter of Dr. Cleven- 
ger's book, and reference is made wherever discussions occurred in 
American medico-legal societies. 

There are abundant illustrations, particularh' for Electro-diagnosis, 
and to enable a clear comprehension of the anatomical and pathological 
relations. 

The Chapters are: 1. Historical Introduction; II. Eriehsen on 
Spinal Concussion : III. Page on Injuries of the Spine and Spinal Cord: 
IT. Recent Discussions of Spinal Concussion : V. Oppenheim on Trau- 
matic Neuroses ; YI. Illustrative Cases from Original and all other 
Sources; YII. Traumatic Insanity; YIII. The Spinal Column; IX. 
Symptoms: X. Diagnosis; XI. Pathology: XII. Treatment; XIII. 
Medico-legal Considerations. 

Other special features consist in a description of modern methods 
of diagnosis by Electricity, a discussion of the controversy concerning 
hysteria, and the author's original pathological view that the lesion is 
one involving the spinal s^^mpathetic nervous system. In this latter 
respect entirely new ground is taken, and the diversity of opinion con- 
cerning the functional and organic nature of the disease is aftbrded a 
basis for reconciliation. 

E\-eni Phf/.^ician and Lawijer should own this work. 

In one handsome Royal Octavo Volume of nearly 400 pages, with 
Thirty Wood-Engravings. Net price, in United States and Canada, 
$2.50, post-paid ; in Great Britain, Ms. 3d. ; in France, 15 fr. 

.; ^F. A. DAVIS: Medical Publisher, Philadelphia, Pa.. U.S.A.) 



JUST READY-A NEW AND IMPORTANT WORK, 



ESSAY 



MEDICAL PNEDMATOLOGY#AEROTHERAPY: 

A PRACTICAL INVESTIGATION OF THE CLINICAL AND THERAPEUTIC VALUE 

OF THE GASES IN MEDICAL AND SURGICAL PRACTICE, WITH ESPECIAL 

REFERENCE TO THE VALUE AND AVAILABILITY OF 

OXYGEN, NITROGEN, HYDROGEN, AND NITROGEN MONOXIDE. 

By d. N. DEMARQUAY, 

Surgeon to the Municipal Hospital, Paris, and of the Council of State ; Member of the Imperial Society 

of Surgery; Correspondent of the Academies of Belgium, Turin, Munich, etc. ; Officer 

of the Legion of Honor ; Chevalier of the Orders of Isabella-rhe- 

(.^atholic and of the Conception, of Portugal, etc. 

TRANSLATED, WITH NOTES, ADDITIONS, AND OMISSIONS, 

By SAMUEL S. WALLIAN, A.M., M.D., 

Member of the American Medicfal Association ; Ex-President of the Medical Association of Northern New 
York ; Member of the New York Coimtj" Medical Societj', etc. 



In one Handsome Octavo Volume of 316 Pages, Printed on Fine Paper, in the Best 
Style of the Printer's Art, and Illustrated vrltli 21 Wood-Cuts. 

United States. Caaada (duty raid). Great Britain. France. 

NET PRICE, CLOTH, Post-paid, S2.00 S2.20 8s. 6d. 12 fr. 40 

14-KUSSIA, " 3.00 3.30 13s. 18 fr. 60 



For some years past there has been a growing demand for something more satisfac- 
tory and more practical in the way of literature on the subiect of what has, by common 
consent, come to be termed '" Qxygen Therapeutics." On all sides professional men of 
standing and ability are turning their attention to the use of the gaseous elements about 
us as remedies in disease, as well as sustainers in health. In prosecuting their inquiiies. 
the first hindrance has been the want of any reliable, or in aday degree satisfactory, 
literature on the subject. 

Purged of the much quackery heretofore associated with it, Aerotherapy is now 
recognized as a legitimate department of medical practice. Although little noise is made 
about it, the use of Oxygen Gas as a remedy has increased in this country within a few 
years to such an extent that in New York City alone the consumption for medical pur- 
poses now amounts to more than 300,000 gallons per annum. 

This work, translated in the. main from the French of Professor Demarquay, contains 
also a very full account of recent English, German, and American experiences, prepared 
by Dr. Samuel S. AVallian. of New York, whose experience in this field antedates that of 
any other American writer on the subject. 



Plain Talks on Avoided Subjects. 

— BY — 

HENRY N. GUERNSEY, M.D., 

Formerly Professor of Materia Medica and Institutes in the Hahmemann Medical College of Philadelphia; 

Author of Guernsey's " Obstetrics," including the Disorders Peculiar to Women and 

Young Children ; Lectures on Materia Medica, etc. 



IN ONE NEAT 16mo VOLUME. BOUND IN EXTRA CEOTH. Price, Post-paid, in 
United States and Canada, SI. 00; Great Britain, 4s. 6d.; France, 6 fr. 30. 



This is a little volume designed to convey information upoH one of the most important subjects con- 
nected with our physical and spiritual well-being, and is adapted to both sexes and all ages and conditions 
of society ; in fact, so broad is its scope that no human being can well afford to be without it, and so com- 
prehensive in its teachings that, no matter how well informed one may be, something can yet be learned from 
this, and yet it is so plain that any one who can read at all can fully understand its meaning. 

The Author, Dr. H. N. Guernsey, has had an unusually long and extensive practice, and his teachings in 
this volume are the results of his observation and actual experience with all conditions of human life. 

His work is warmly indorsed by many leading men in all branches of professional life, as well as by 
many whose business connections have caused them to be close observers. 

The following Table of Contents shows the scope of the book : — 

CONTENTS. Chapter I.— Introductory. II.— The Infant. III.— Childhood. IV.— Adoles- 
cence OF THE Male. V. — Adolesce.nce of the Female. VI. — Marriage: The Husband. VII. — 
'^^E Wife. VIII.— Husband and Wife. IX.— To the Unfortunate. X.— Origin of the Sex. 

CF. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 7 



]KH1¥ BDIXION- 



Lessons in Gynecology. 

By W^ILLIAM GOODELL, A.M., M.D., Etc., 

Professor of Clinical Gynecology in the University of Pennsylvania. 

IFTitli 118 Illastratioiui. Third JEdition, Thoroughly Revised and Greatly Enlarged, 
ONE VOLUME, LARGE OCTAVO, 578 PAGES. 



This exceedingly valuable work, from one of the most eminent specialists and teachers in gynecology 
in ibe United States, is now offered to the profession in a much more complete condition than either of the 
previous editions. It embraces all the more important diseases and the principal operations in the field of 
gynecology, and brings to bear upon them all the extensive practical experience and wide reading of the 
author. It is an indispensable guide to every practitioner who has to do with the diseases peculiar to 



Fig. 44. 




Katural Position of the Womb When the Bladder is Full. 
After Briesky. 



Tfcese lessons are so well known that it is en- 
tirely unnecessary to do more than to call attention 
to the fact of the appearance of the third edition. 
It is too good a book to have been allowed to remain 
out of print, and it has unquestionably been missed. 
The author has revised the work with special care, 
adding to each lesson such fresh matter as the prog- 
ress in the art rendered necessary, and he has en- 
larged it by the insertion of six new lessons. This 
edition will, without question, be as eagerly sought 
for as were its predecessors. — American Journal 
t>f Obstetrics. 

The former editions of this treatise were well 
received by the profession, and there is no doubt 
that the new matter added to the present issue makes 
it more useful than its predecessors. — New York 
Medical Record. 

His literary style is peculiarly charming. There 



is a directness and simplicity about it which is easier 
to admire than to copy. His chain of plain words 
and almost blunt expressions, his familiar compari- 
son and homely illustrations, make his writings, like 
his lectures, unusually entertaining. The substance 
of his teachings we regard as equally excellent. — 
PJiila. Medical and Surgical Reporter. 

Extended mention of the contents of the book i.-^ 
unnecessary'; suffice it to say that every important 
disease found in the female sex is taken up and dis- 
cussed in a common-sense kind of a way. We wish 
every physician in America could read and carry 
out the suggestions of the chapter on " the sexual re- 
lations as causes of uterine disorders — conjugal 
onanism and kindred sins." The department treat- 
ing of nervous counterfeits of uterine diseases i.-. 
a most valuable one. — Kansas City Medical 
Index. 



Price, in United States and Canada, Cloth, $5.00; Pull Sheep, $6.00. Discount, 20 per 

cent., making it, net, Cloth, $4.00; Sheep, $4.80. Postage, 27 Cents eztra. Great 

Britain, Cloth, 18s. ; Sheep, £L2s., post-paid, net. France, 30 fr. 80. 



(F. A. DAVIS. Medical Publisher, Philadelphia, Pa., U.S.A. 



AMERICAN RESORTS, 

WITH NOTES UPON THEIR CLIMATE 

of the American Association for the Advancement of Science, the American Public llenlth Association, the 
Pennsylvania Historical Society, the Franklin Institute, and the Academy of Natural >cienccs. Phi'atlelphia : 
the Society of Alaskan Natural History and Ethnology,' Sitka. Alaska, etc. 

WITH A TRANSLATION FROM THE GERMAN, By Mr. S. KAUFFMANN, 

»f those chapters of " Die Klimate der Erde" written by Dr. A. Woeikof, of St. Petersburg, Russia, that 
relate to North and South America and the islands and oceans contiguous thereto. 



Xn One Octavo Volume. Handsomely Bound in Cloth. Nearly 300 Pages., Price, 
Post-paid, in U. S. and Canada, S2.00, net. Great Britain, 8s. 6d. France, 12ffr. 40. 



This is a unique and valuable work, and useful to physicians in all parts of the country. It is just such 
a volume as the Medical Profession have stood in need of for many years. We mention a fewof the merits 
it possesses: First. List of ail the Health Resorts of the country, arranged according to their climate. 
Secofid. Contains just the information. needed by tourists, invalids, and those who visit summer or winter 
resorts. Third. The latest and best large railroad map for reference. Fourth. It indicates the climate 
each one should select for health. Fifth. The author has traveled extensively, and most of his suggestions 
are practical in reference to localities. 

Taken altogether, this is by far the most complete ex- ' ■ ought, as it deserves, to receive a hearty welcome from the 
position of the subject of resorts that has yet been put profession. — Medical Advance. 

forth, and it is one that every physician must "needs possess The l>ook before us is a very comprehensive volume, 

intelligent information upon. We predict a large demand : giving all necessary information concerning climate, tem- 
for this useful and attractive book.— .Bu^fa to Med. and . perature. humidity, sunshine, and indeed everything neees- 
Surg. Jour. ~ I ^ sary to be stat«d for the benefit of the physician or invalid 

The special chapter on the therapeutics of climate . . )i seeking a health resort in the United States. — Southern 
is excellent for its precautionary sxiggestions in the selec- 'i Clinic. 

tion of climates and local conditions, with reference to i ! This work is extremely valuable, owing to the liberal 

known pathological indications and constitutional predis- ; j and accurate manner in which it gives information regard- 
'lositions. — The Snnifnrian. ' ' ing the various resorts on the Ajierican continent, without 

It is arranged in such a manner that it will be of great | , being prejudiced in the least in favor of any particular one. 
service to medical men whose duty it often becomes to reo ; i but giving all in a fair manner. ..." All physicians 
ommend a health resort.— X. W.' Med. Jour. \\ need just such a work, for the doctor is always asked to 

A well-arranged map of the United States serves as the I i give information on the siibject to his patients. Therefore, 
frontispiece of the book ; and an almost perfect index is I j it should find a place in every physician's library. — The 
appended, while between the two is an amount of informa- I Med. Brier". 

tion as to places for the health-seeker that cannot be gotten i ] The author of this admirable work has long made a 

elsewhere. We most cordially recommend the book to j ] study of American cliraaie, from the stand-point of a phy- 
travelers and to the doctor. — Virginia Med. Monthly. \ i sician. with a ^-iew to ascertaining the most si;itable locali- 

This is a work that has loi^ been needed, as there is j ' ties for the residence of invalids, believing proper climate 
scarcely a physician who has not had occasion to look up ' to be an almost indispensable factor in the treatment, pre- 
the authorities on climate, elevation, dryness, humidity, ' [ vention, and cure of many-forms of disease. . . . The 
etc . etc.. of the various health resorts, and has had great ' ' book evidences careful research and furnishes much useful 
difficulty in finding reliable information. It sertainly ,i information not to be found elsewhere. — Pacific Med. Jour. 



JUST PUBLISHED 



RECORD-BOOK OF MEDICAL EXAMINATIONS 

For Life Insurance. 



In examining for Life Insurance, questions are easily overlooked and the answers to 
i;hein omitted ; and, as these questions are indispensable, they must be answered before the 
case can be acted upon, and the examiner is often put to much inconvenience to obtain 
this information. 

The need has long been felt among examiners for a reference-book in which could be 
noted the principal points of an examination, and thereby obviate the necessity of a 
second visit to the applicant when further information is required. 

After a careful study of all the forms of examination blanks now used by Insurance 
Companies, Dr. J. M. Keating has compiled such a record-book which we are sure will fill 
this long-felt want. 

This record-book is small, neat, and complete, and embraces all the principal points 
that are required by the different companies. It is made in two sizes, viz. : No. 1, cover- 
ing one hundred (100) examinations, and No. 2, covering two hundred (200) examina- 
tions. The size of the book is 7 x 3f inches, and can be conveniently carried in the 
pocket. 

NEX PRICKS, I»OSX-I»AID. 

U. S. and Canada. Great Britain. France. 

No. 1, For 100 Examinations, in Cloth, - $ .50 3s. 6d. 3 fr. 60 

No. 2, For 200 Fxaminations, in Full 

L.eather, with Side Flap, . - . . i.oo 4s. 6d. 6 fr. 20 



(F. A. DAVIS, Metlical Publisher, Philadelphia, Pa., U.S A.) 



DISEASES' 



Heart and Circulation 

IN INFANCY AND ADOLESCENCE. 



•1 



l^itli an Appendix: entitled ^^ Clinical Studies on tlie 
Pulse in Cliildliood.'' 



JOHN M. KEATING, M.D., 

Obstetrician to the Philadelphia Hospital^ and Lecturer on Diseases of Women and Children; Surgeon to> 

the Maternity Hospital ; Physician to St, Joseph's Hospital ; Fellow of the 

College of Physicians of Philadelphia, etc.. 



^A^ILLIAM A. EDAA^ARDS, M.D., 

Instructor in Clinical Medicine and Physician to the Medical Dispensary in the University of Pennsylvania ; 

Physician to St. Joseph's Hospital ; Fellow of the College of Physicians ; formerly 

Assistant Pathologist to the Philadelphia Hospital, etc. 



ILLUSTRATED BY PHOTOGRAPHS AND WOOD-ENGRAVINGS. 



About 225 Pages. 8vo. Bound in Cloth. Price, 
and Canada, $1.50, net; Great Britain, 6s. 6d. ; 



post-paid, in U. S.. 
France, 9 fr. 35. 



There are many excellent text -books on children's diseases, but they have failed to give a satisfactory 
r.ccount of the diseases of the heart ; and, indeed, as far as known, this work of Keating and Edwards' njw 
presented to the profession is the only systematic attempt that has been made to collect in book form the 
abundant material which is scattered throughout medical literature in the form of journal articles, clinical, 
lectures, theses, and reports of societies. 

The authors have endeavored, in their difficult task, to collect these valuable materials and place them 
within easy reach of those who are interested in this important subject. That they have succeeded will, we 
believe, be conceded by all who obtain and make use of their very valuable contribution to this hitherto- 
neglected field of medical literature. 

An appendix, entitled " Clinical Studies on the Pulse in Childhood," follows the index in the book, and 
will, we are sure, be found of much real value to every practitioner of medicine. The work is made available 
for i-eady reference by a well-arranged index. We append the table of contents showing the scope of the- 
book : — 



Chapter I. — The Methods of Study — Instruments — 

Foetal Circulation — Congenital Diseases of the 

Heart — Malformations — Cyanosis, 
Chapter II. — Acute and Chronic Endocarditis — 

Ulcerative endocarditis. 
Chapter HI.— Acute and Chronic Pericarditis. 
Chapter IV.— The treatment of Endo- and Peri- 
_ carditis — Paracentesis Pericardii — Hydropericar- 

dium — Haemopericardium — Pneumopericardium. 
Chapter V.— Myocarditis — Tumors, New Growths, 

and Parasites. 
Chapter VI.— Valvular Di.sease: Mitral, Aortic, 

Pulmonary, and Tricuspid. 



Chapter VII. — General Diagnosis, Prognosis, and 
Treatment of Valvular Disease. 

Chapter VIII. — Endocarditis — Atheroma — Aneu- 
rism. 

Chapter IX. — Cardiac Neuroses — Angina Pectoris 
— Exophthalmic Goitre. 

Chapter X. — Diseases of the Blood: Plethora, 
Anaemia, Chlorosis, Pernicious Anaemia, Leu- 
kaemia — Hodgkin's Disease — Haemophilia, Throm- 
bosis, and Embolism. 

INDEX. 

APPENDIX.— Clinical Studies on the Pulse 
IN Childhood. 



Drs. Keating and Edwards have produced a work that 
will give material aid to every doctor in his practice among 
children. The style of the book is graphic and pleasing, 
the diagnostic points are explicit and exact, and the thera- 
peutical resources include the novelties of medicine as well 
as the old and tried ngents.— Pi t/shin-f/h Med. Btwiew. 

A very attractive and v.aluable work has been given to 
the medical profession by Drs. Keating and Edwards, in 
their treatise on the diseases of the lieai-t and circulation 
in infancy and adolescence, and they deserve the greatest 
credit for tlie admirable manner iu which they have col- 
lected, reviewed, and made use of the immense amount of 
material on this important syih^nct.— A n-Mves of Pediatrics. 

The plan of the M'ork is the correct one, viz., the sup- 
plementing of the observations of the better class of prac- 
titioners by the experience of those who have given the 
subject systematic attention, — Medical Age. 



It is not a mere compilation, but a systematic treatise,, 
and bears evidence of considerable labor "and observation on- 
the part of the authors. Two fine photographs of dissec- 
tions exhibit mitral steiiosis and mitral regurgitation ; 
there are also a number of wood-cuts. — Cleveland Medicat 
Gazette. 

As the works upon diseases of children give little or na 
attention to diseases of the heart, this work of Drs. Keat- 
ing and Edwards will supply a want. We tbinli that 
there will be no )ihysician. who takes an interest in the 
affections of young folks, who will not wish to consult it. 
— Ciiiciniiofi Med. Neics. 

The work takes up, in an able and scientific manner, 
diseases of the heart in children. This is a part of the 
field of medical science which has not been cultivated tO' 
the extent that the importance of the subject desen-es.— 
Canada Lancet. 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



PERPETUAL CLINICAL INDEX 

— TO — 

MATERIA MEDICA, CHEMISTRY, AND PHARMACY CHARTS. 
By A. H. KELLER, Ph.G., M.D. 

Consisting of (1) the "Perpetual Clinical Index," an oblong volume, 9x6 inches, 
neatly bound m extra Cloth ; (3) a Chart ot "Materia Medica," 32 x44 inches, 
mounted on muslin, with rollers ; (3) a Chart of " Chemistry and Phar- 
macy," 32 x44 inches, mounted on muslin, with rollers. 

United States. Canada (duty paid). Great Britain. France. 

Net Price for the Complete Work, $5.00 $5.50 £l.ls. 30fr. 30 



Read the Following Description and Esplanation of the Work : 

In presenting the objects and advantages of these Charts and " Perpetual Clinical Index" it becomes 
necessary to state that the Author's many years' e.xperience as a physician and Pharmacist enables him 
to produce, m terse language, a volume of facts that must be of inestimable value to the busy physician and 
pharmacist, or to any student of either profession. He has endeavored to describe all that have borne inves 
tigation up to date. 

The system will prove to be of great value in this, that so little labor will be required to add new 
inv^estigation as fast as may be gathered from new books, journals, etc. The classification is alphabetical 
and numerical in arrangement, and serves so to unite the various essentials of Botany, Chemistry and 
Materia Medica, that the very thought of the one will readily associate the principal properties and uses as 
well as Its origin -r r r c , a 

TT J'jf "J>*ATEKIA IVIEDICA" CHART, in the first place, aids at a glance: ist. Botanical or 
U. b. P. ^ame; 2d, The Common Mame; -^d. Natural Order; 4th, Where Indigenous; 5th, Principal Con- 
.stituent; 6th, Part Ijsed— herbs, leaves flowers, roots, barks, etc. ; 7th, Medicinal Properties— mainly con- 
sidered; 8th, I he Dose — medium and large. 

On this Chart there are 475 first names ; Section A. is numbered from i to 5g, each section commencing 
with the capital letter, and having its own numbers on both left-hand and right-hand columns, to prevent 
mistakes in lining out, all in quite large type. In the centre of the Chart, occupying about 6 inches in 
width, is a term index of common names. In the second column of Chart, like this : 

Aconite Leaves, 4 A. 

Then by reference to 4 A in first column, you there find the Botanical or U. S. P. Name! On this Chart is 
also found a brief definition of the terms used, imder the heading " Medicinal Properties " 
.u AA- ."^-^HEMISTKY" CHART takes in regular order the U. S. Pharmacopoeia Chemicals, with 
the additiori of many new ones, and following the name, the Chemical Formula, the Molecular Weight and 
next the Origin. 1 his is a brief but accurate description of the essential points in the manufacture : ' The 
.Uose, medium and large: next, Specific Gravity; then, whether Salt or Alkaloid; next. Solubilities by 
abbreviation, in Water, Alcohol, and Glycerine, and blank columns for solubilities, as desired. 

Alkaloids and Concentrations are tabulated with reference numbers for the Perpetual Clinical Index, giving 
Medicinal Properties , Minute Dose and Large Dose. For example. Alkaloids and Concentrations : 

^- i Medicinal Properties. Minute Dose, j Large Dose. 



1-500 gr. 



(a) Aconitine. j Narcotic and Apyretic. 

Following this. Preparations of the Pharmacopoeia, each tabulated. For example 



TINCTURAL. 



Tinctura. I Drug. j Amount. | Alcohol. I Dose. 



* Arnni-ti S Aconite. ^ . 

Acomti. I J Tartaric Acid, 60 t P. 554 oz. to 24 gr. 



to 3 drops. 



* 60 Fineness of Powder as per U. S. P. 

t P. Macerate 24 hours. Percolate, adding Menstruum to complete (1) pint tincture 



They are all thus abbreviated, with a ready reference head-note. 
_ Next, Thermometers, Metric Table of Weights, Helps to the Study of Chemistry. Examples in Work- 
ing Atomic Molecular Formulae. Next, Explanation of Terms Used in Columns of Solubilities List of 
Pharma?^°"^"^ t-lements Now in Use, and Definitions or Terms Frequently Used in Chemistry anci 

The '«PERPETUAI. CI.INICAL INDEX " is a book 6 by 9 inches, and one-half inch thick. 
It contains 135 pages, divided as follows (opposite pages blank) : 

The Index to Chemistry Chart occupies two pages ; Explanations, Abbreviations, etc., forty pages with 
diseases, and with an average of ten references to each disease, leaving room for about forty more remedies 
for each disease. The numbers reler to the remedies used in the diseases by the most celebrated physicians 
and surgeons, and the abbreviations to the manner in which they are used. Eight pages numbered and 
bracketed, for other diseases not enumerated. The Materia Medica, E.xplanations, Abbreviations and 
Remedies suggested for occupy twenty-six pages. For Abbreviated Prescriptions, seventeen blank pages 
Ihen the Index to Alkaloids and Concentrations. These, already enumerated, with their reference number 
six blank tabulated pages, for noting any new Alkaloids and Concentrations. Then the Chemistry Index 
giving the same number as on Chart, with Name, Doses, Specific Gravity, Salt or Alkaloid in the .same 
line, as for example : 



Name. | Doses. j Specific Gravity. Salt or Alkaloi 



Memora.n'da. 



This Memoranda place is for Physicians' or Pharmacists' reference notes ; and with the addition of 
several tabulated blank pages in which to add any new chemical, with doses, etc. The remaining sixteen 
pages for xMateria Medica Index, leaving blanks following each other for new names and reference numbers 
io show the ready and permanent use of the "Perpetual Clinical Index" of the "Chemistry" and 
Pharmacy Charts or Inaex in the book, suppose the Physician reads in a book or journal that Caffeine 
Utras IS useful in the disease Chorea, and he wishes to keep a permanent record of that, he refers to the 
Chart and if it does not already appear there, it can be placed opposite and numbered, and thereafter used 
tor reference. But we find its permanent number is No. 99. so he will write down in the line left blank for 
lutureuse mhisbook, in line already used, running parallel with other reference numbers in Chorea the 
No. 99, and immediately under he can u.se the abbreviation in the manner in which it is given Though 
years may have passed, he can in a moment, by referring there, see that No. 99 is good for Chorea If fail- 
ing to remember what No. 99 is, he glances at the Chart or Index. He sees that No. 99 is Caffeine Citras 
and he there learns its origin and dose and solubility, and in a moment an intelligent prescription can be 

(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S. A. J ii 



New Edition of an Important and Timely Work Just Published. 



Electricity In the Diseases of ^omen, 

"With Special Reference to the Application of Strong Currents. 

By G. BETTON MASSEY, M.D., 

physician to the Gynecological Department of Howard Hospital ; Late Electrd-Therapeutist to the Phila- 
delphia Orthopaedic Hospital and Infirmary for Nervous Diseases ; Member of the American 
Neurological Ass'n, of the Philadelphia Neurological Society, of the Franklin Institute, etc. 



Secoan-d. :Bd.it5.023.. 



Z5.e-^ised. a-ri-d. IBaa-lsLrg-ed.. 



WITH NEW AND ORIGINAL WOOD-ENGRAVINGS. HANDSOMELY BOUND IN CLOTH. OVER 200 PAGES. 

12mo. Price, in United States and Canada, $1.50, net, post-paid. 

In Great Britain, 6s. 6d. In France, 9 £r. 35. 



This work is presented to the profession as the most complete treatise yet issued o» 
the electrical treatment of diseases of women, and is destined to fill the increasing demand 
for clear and practical instruction in the handling and use of strong currents after the 
recent methods first advocated by Apostoli. The whole subject is treated from the present 
stand-point of electric science with new and original illustrations, the thorough studies of 
the author and his wide clinical experience rendering him an authority upon electricity 
itself and its therapeutic applications. The author has enhanced the practical value of 
the work by including the exact details of treatment and results in a number of cases 
taken from his private and hospital practice. 




Fig. 15. — Author's Fibroid Spbar. 




Fig. 18. — Ball Electrode for Administering Franklinic Sparks. 



Chapter I, Introductory ; II, Apparatus required in gynecological applications of the galvanic current ; 
III, Experiments illustrating the physical qualities of galvanic currents ; IV, Action of concentrated gal- 
vanic currents on organized tissues ; V, Intra-uterine galvano-chemical cauterization; VI, Operative details 
•f pelvic electro-puncture; VII, The faradic current in gynecology ; VIII, The franklinic current in gyne- 
cology ; IX, Non-caustic vaginal, urethral, and rectal applications ; X, General percutaneous applications in 
tfie treatment of nervous women ; XI, The electrical treatment of fibroid tumors of the uterus ; XII, The 
electrical treatment of uterine hemorrhage; XIII, The electrical treatment of subinvolution; XIV, The 
electrical treatment of chronic endometritis and chronic metritis ; XV, The electrical treatment of chronic 
diseases of the uterus and appendages; XVI, Electrical treatment of pelvic pain; XVII, The electrical 
treatment of uterine displacements ; XVIII, The electrical treatment of e.xtra-uterine pregnancy ; XIX, 
The electrical treatment of certain miscellaneous conditions ; XX, The contra-indications and limitations to 
the use of strong currents. 

An Appendix and a Copious Index, including the definitions of terms used in the work, concludes 
the book. 



The author gives us what he has seen, and of which 

he is assured by scientific study is correct W© 

are certain tliat this little work will prove helpful to all 
physicians who desire to use electricity in the management 
of the diseases of women.— T/ie American Lancet. 

To say that the author is rather conservative in his 
ideas of the curative powers of electricity is only another 
way of saying that he understands his subjeet thoroughly. 
The mild enthusiasm of our author is unassailable, because 
it is founded on science and reared with experience.— TAe 
Medical Analecttc. 

The work is well written, exceedingly practical, and 
•an be trusted. We commend it to the profession."— ifary- 
land Medical Journal. 

The book is one which should be possessed by every 
physician who treats diseases of women by electricity .— 
The Brooklj^n Medital Jonrnal. 

The departments of electro-physics, pathology, and 
el«ctro-therapeutics are thoroughly and admirably con- 



sidered, and by means of good wood-cuts the beginner has 
before his eye the exact method of work required.— 27je 
Medical Register. 

" The author of this little volume of 210 pages ought 
to have added to its title, " and a most happy dissertation 
upon the methods of using this medicinal agent ; " for in 
the first 100 pages he has contrived to describe the lechni 
of electrization in as clear and happv a manner as h* 
author has ever succeeded in doing, ancf for this part of the 
book alone it is almost priceless to the beginner in the 

treatment with this agent The little book is 

worthy the perusal of every one at all interested is th« 
subject of electricity in medicine. — The Omaha Clinic. 

The treatment of fibroid t«mor of the uterus will, 
perhaps, interest the profession more generally than any 
other question. This subjeet has been accorded ample 
space. The method of treatment in many cases has ^» 
recited in detail, the results in every instance reported be- 
ing beneficial, and in many curative.— Pacyfc Med. J0ur. 



12 



(F. A. DAVIS. Medical Publisher, Philadelphia, Pa., U.S.A.) 



Iv^ 



PRACTICAL SURGERY. 

By J. E^^ING ]»IKARS, m.D., 

Lecturer on Practical Surgery and Demonstrator of Surgery in Jefferson Medical College; Professor of 
Anatomy and Clinical Surgery in the Pennsylvania College of Dental Surgery, etc. 



With 490 Illustrations. Second edition, revised and enlarged. 791 pp. 12mo. 



PRICE, IN UNITED STATES AND CANADA : CLOTH, $3.00. DISCOUNT, 20 PER CENT., MAKING IT, NET. 
$2.40; POSTAGE. 20 CENTS EXTRA. GREAT BRITAIN, 13s. FRANCE, 18 fr. 75. 



Mears' Practical Surgery includes chapters on Surgical Dress- 
ings, Bandaging, Fractures, Dislocations, Ligature of Arteries, Amputa- 
tions, Excisions of Bones and Joints. This 
work gives a complete account of the 
methods of antiseptic surgery. The dif- 
ferent agents used in antiseptic dressing, 
their methods of preparation, and their 
application in the treatment of wounds are 
full}' described. With this work as a guide 
it is possible for every surgeon to practice 
antiseptic surgery. The great advances 
made in the science and art of surgery are 
largely due to the- introduction of anti- 
septic methods of wound treatment, and it 
is incumbent upon ever}" progressive sur- 
geon to employ them. 

An examination of this work will 
show that it is thoroughly systematic in 
its plan, so that it is not onty useful to the practitioner, who ma}" be 
called upon to perform operations, but of great value to the student in 
his work in the aurgical room, where he is required to apply bandages 
and fracture dressings, and t6 perform operations upon the cadaver. The 
experience of the author, derived from man}" years' service as a teacher 
(private and public) and practitioner, has enabled him to present the 
topics discussed in such a manner as to fully meet the needs of both prac- 
titioners and students. 




It is full of common sense, and may be safely 
taken as a guide in the matters of which it treats. 
It would be hard to point out all the excellences of 
this book. We can heartily recommend it to students 
and to practitioners of surgery. — Avierican your- 
nal of the Medical Sciences. 

We do not know of any other work which would 
be of greater value toAe student in connection with 
his lectures in this d^artment. — Buffalo Medical 
tind Siirgical yonr7ial. 

The work is excellent. The student cr practi- 



tioner who follows it intelligently cannot easily go 
astray. — yonrnal Amer-ican JMedical Asso' n. 

We cannot speak too highly of the volume under 
review. — Canada JSIcd. and Sierg: your. 

The space devoted to fractures and dislocations 
— by far the most difficult and responsible part of 
surgery — is ample, and we notice many new illustra- 
tions explanatory of the text. — North Carolina 
Medical yournal. 

It is one of the most valuable of the works of its 
kind.— A'Vw Orleans Med. and Surg. your. 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



13 



AN ENTIRELY NEW PHYSICIAN'S VISITING LIST. 
== "THE .== 

Medical Bulletin Visiting List 

OR 

PHYSICIAN'S QaLL f^ECORD. 



ARRANGED UPON AN ORIGINAL AND CONVENIENT MONTHLY AND WEEKLY PLAN 
FOR THE DAILY RECORDING OF PROFESSIONAL VISITS. 



Frequent Rewriting of Names Unnecessary. 

This Visiting List is arranged upon a plan best adapted to the most 
convenient use of all physicians, and embraces a new feature in recordinor 
daily visits riot found in any other list, consisting of stub or half leaves 
in the form of inserts, a glance at which will suffice to show that as the 
first week's record of visits is completed the next week's record ma}' be 
made by simply turning over the stub-leaf, without the necessity of re- 
writing the patients' names. This is done until the month is completed, 
and the phj^sician has kept his record just as complete in every detail of 
VISIT, CHARGE, CREDIT, etc, as he could have done had he used any of the 
old-style visiting lists, and has also saved himself three-fourths of the 
time and labor formerly required in transferring names every week. 
There are no intricate rulings ; everything is easily and quickly under- 
stood ; not the least amount of time can be lost in comprehending the 
plan, for it is acquired at a glance. 

The Three Different Styles Made. 

The iVo. 1 Style of this List provides ample space for the daily 
record of sevent}^ (70) diflferent names each month for an entire 3'ear 
(two full pages, tbirty-five [35] names to a page, being allowed to each 
month), so that its size is sufficient for an ordinary practice ; but for 
physicians who prefer a List that will accommodate a larger practice we 
have made a jVV>. 2 Style^ which provides ample space for the daily 
record of one hundred and five different names (105) each month for 
an entire year (three full pages being allowed to each month), and for 
physicians who may prefer a Pocket Record Book of less. thickness than 
either of these styles we have made a JVo, 3 Style^ in which " The 
Blanks for the Recording of Visits In " have been made into removable 
sections. These sections are very thin, and are made up so as to answer 
in full the demand of the largest practice, each section providing ample 
space for the daily record of two hundred and ten (210) different 
NAMES for one month; or one hundred and five (105) different names 
daily each month for two months ; or seventy (70) different names daily 
each month for three months ; or thirty-five (35) different names daily 
each month for six months. Four sets of these sections go with each 
copy of No. 3 Style. 

Special Features Not Found in Any Other List. 

In this No. 3 Style the printed matter, and such matter as the 
blank forms for Addresses of Patients, Obstetric Record, Vaccination 
Record, Cash Account, Births and Deaths Records, etc., are fastened 
permanently in the back of the book, thus reducing its thickness. The 
addition of one of these removable sections does not increase the size 
quite an eighth of an inch. This brings the book into such a small com- 
pass that no one can object to it on account of its thickness, as its bulk 

14 



IS VERY MUCH LES6 tliaii that of any visiting list ever published. Every 
physician will at once understand that as soon as a section is full it can 
be taken out, filed tiv^ny, and another inserted without the least incon- 
venience or trouble. 

Tliis Visiting List contains a Calendar for the last six months 
of last year, all of this, and next year; Table of Signs to be used 
in Keeping Accounts; Dr. Ely's Obstetrical Table; Table of Cal- 
■culating the Number of Doses in a given H, etc., etc, ; for converting 
Apothecaries' Weights and Measures into Grammes ; Metrical Avoirdu- 
pois and Apothecaries' Weights ; Number of Drops in a Fluidrachm ; 
Graduated Doses for Children ; Graduated Table for Administering 
Laudanum ; Periods of Eruption of the Teeth ; The Average Frequency 
of the Pulse at Different Ages in Health ; Formula and Doses of Hypo- 
dermic Medication; Use of the Hypodermic Syringe; Formulae and 
Doses of Medicine for Inhalation ; Formulae for Suppositories for the 
Rectum ; The L^se of the Thermometer in Disease ; Poisons and their 
Antidotes ; Treatment of Asphj'-xia ; Anti-Emetic . Remedies ; Nasal 
^Douches ; Eye-Washes. 

Most Convenient Time- and Labor- Saving List Issued. 

It is evident to everv one that this is, beyond question, the best and 
most convenient time- and labor-saving Physicians' Record Book ever 
published. Physicians of many j^ears' standing and with large practices 
pronounce this the Best List they have ever seen. It is handsomel}' 
bound in fine, strong leather, with flap, including a pocket for loose 
memoranda, etc., and is furnished with a Dixon lead-pencil of excellent 
quality and finish. It is compact and convenient for carrj ing in the 
pocket. Size, 4 x 6 J inches. 

IJ« THR.HE STYI^ES-]SK'r PRICES, I»OSX-I»AIO. 

U. S. aad Canada. Great Britaiu. Frauce. 
Regular Size, for 70 patients daily each month for one year, $1.36 os. 3. 7 tr. 75 

Large Size, for 105 patients daily each month for one year, 1.50 6s. 6. 9 fr. 35 

In which "The Blanks for Recording Visits in" are in re- 
movable sections, as described above, . - - - 1.75 7s. 3. 12 fr. 20 



No. I. 
No. 2. 
No. 3. 



EXTRACTS FROM REVIEWS. 



" While each page records only a week's visits, 
■yet by an ingenious device of half leaves the names 
=of the patients require to be written but once a 
month, and a glance at an opening of the book 
shows the entire visits paid to any individual in a 
month. It will be found a great convenience." — 
Boston Medical and Surgical Journal. 

"Everything about it is easily and quickly 
understood." — Canadian Practitioner. 

"Of the many visiting lists before the profes- 
sion, each has some special feature to recommend 
it. This list is very ingeniously arranged, as by a 
series of narrow leaves following a wider one, the 
name of the patient is written but once during the 
month, while the account can run for thirty-one 
•days, space being arranged for a weekly debit 
and credit summary and for special memoranda. 
The usual pages for cash account, obstetrical 
record, addresses, etc., are included. A large 
amoimt of miscellaneous information is presented 
in a condensed form." — Occidental Medical 
Times. 

"It is a monthly instead of a weekly record, 
thus obviating the transferring of names oftener 
than once a month. There is a Dr. and Cr. column 
following each week's record, enabling the doctor 
to carry a patient's account for an indefinite time, 
or imtil he is discharged, with little trouble." — 
Jndiana Medical yournal. 



"Accounts can begin and end at any date. 
Each name can be entered for each day of every 
month on the same line. To accomplish this, four 
leaves, little more than one-third as wide as the 
usual leaf of the book, follow each page. Oppo- 
site is a full page for the recording of special 
memoranda. The usual accompaniments of this 
class of books are made out with care and fitness." 
— The America7i Lancet. 

"This is a novel list, and an unusually con- 
venient one." — Jourfial of the Amer. Med. Assoc. 

"This new candidate for the favor of physi- 
cians possesses some unique and useful points. 
The necessity of rewriting names every week is 
obviated by a simple contrivance in the make-up 
of its pages, thus saving much valuable time, 
besides reducing the bulk of the book." — Bujff^alo 
Medical and Surgicad Journal. 

"This list is an entirely new departure, and 
on a plan that renders posting rapid and easy. It 
is just what we have often wished for, and really 
fills a long-felt want." — The Medical Waif. 

"It certainly contains the largest amount of 
practical knowledge for the medical practitioner 
in the smallest possible volume, besides enabling 
the poorest accountant to keep a correct record, 
and render a correct bill at a moment's notice." — 
Medical Chips. 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



15 



HAND-BOOK OF ECLAMPSIA; 

OK, 

Notes and Cases of Puerperal ConYulsions. 



E. .MiOHENER, M.D., J. H. Stubbs, M.D., R. B. Ewing, M.D. 

B. Thompson, M.D., S. Stebbins, M.D. 



Price, in United States and Canada, Bound in Cloth, 16mo, Net, 75 Cents; in Great 
Britain, 3 Shillings ; in Prance, 4 fr. 20. 



In our medical colleges the teachers of Obstetrics dwell upon the use of blood-letting (phlebotomy) ia 
cases of puerperal convulsions, and to this method Dr. Michener and his fellows give their unqualified 
support — not to take a prescribed number of ounces, but to bleedf^r effect, andyrom a large orifice. This 
is plainly and admirably set forth in his book. To bleed requires a cutting instrument, — not necessarily a 
lancet, — for Dr. M. states how in one case a pocket-knife was used and the desired effect produced. 

Let the young physician gather courage from this little book, and let the more experienced give testi- 
mony to confirm its teaching. 



We have always thought that this treatment -was 
indorsed, approved, and practiced by physicians generally ; 
and to such as doubt the efficacy of blood-letting we would 
commend this little volume.— &u</terji Clinic. 

The authors are seriously striving to restore the 



"lost art" of blood-letting, and we must commend the 
modesty of their endeavor.— iV^or^A Carolina Med. Jour. 

The cases were ably analyzed, and this plea for vene- 
section should receive the most attentive consideration from.. 
obstetricians. — Medical and Surgical Reporter. 



jTJSi' z^:e]-^id-s-. 



A MANUAL OF INSTRUCTION 



FOR GIVING 



Sf edisli Hoyement ^ Massage Treatient. 



Prok. Hartvio Nisskn, 

Director of the Swedish Health Institute, Washington, D.C. ; Late Instructor in Physical Culture and.: 

Gymnastics at the Johns Hopkins University, Baltimore, Md, ; Author of 

" Health by Exercise without Apparatus." 



ILLUSTRATED WITH 29 ORIGINAL WOOD-ENGRAVINGS. 



In One 12mo Volume of 128 Pages. Neatly Bound in Oloth. Price, 

post-paid, in United States and Canada, Net, $1.00; in 

Great Britain, 4s. 3d. ; in France, 6 fr. 20. 



This is the only publication in the English language treating this very important 
■subject in a practical manner. Full instructions are given regarding the mode of 
applying 

The Swedish Moveient and Massage Treatient 

in various diseases and conditions of the human system with the greatest degree of 
effectiveness. Professor Nissen is the best authority in the United States upon this prac- 
tical phase. of this subject, and his book is indispensable to every physician who wishes t® 
know how to use these valuable handmaids of medicine. 



This manual is valuable to the practitioner, as it 
contains a terse description of a subject but too little under- 
stood in tliis countrv The book is got up very 

credihilily.— ,T. 7' .^r,,^. Jour. 

Tlic |ii(sii,t vdliiiuc is a modest account of the appli- 
cation oC i'i.> Swedish ^tinvetnent and Massage Treatment, 
in which thu tiicliin((uo of the various proceduresare clearly 
stated as well as illustrated in a Very excellent manner. 
— North American Practitioner. 

This little manual seems to be written by an expert, 
and to those who desire to know the details connected with 



the Swedish Movement and Massage we commend th« 
hook.— Practice. 

This attractive little hook presents the subject in a very 
practical shape, and makes it possible for evei\v physician t« 
understand at least how it is applied, if it does not give him 
dexterity in the art of its apjilication. lie can certainly 
acquire dexterity by following the directions so plainly ad- 
viied in this book.— (7/(.ica7'> Med. Times. 

It is so practical and clear in its demonstrations that 
if you wish a work of this nature you cannot do better than-. 
peruse this ono.— Medical Brief. 



16 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



JUST READY— THE LATEST AND BEST PHYSICIAN'S ACCOUNT- 
BOOK EVER PUBLISHED. 



THE PHYSICIAN'S 



ALL-KEQai51TE TlME- 

AH^ Labor 



'?Av™" Account-Book 



BEING A LEDGER AND ACCOUNT-BOOK FOR PHYSICIANS- USE, MEETING ALL 
THE REQUIREMENTS OF THE LAW AND COURTS. 



DESIGNED BY 



Of Elaston, I=a.. 



PROBABLY no class of people lose more money through carelessly kept 
accounts and overlooked or neglected bills than physicians. Often 
detained at the bedside of the sick until late at night, or deprived of 
even a modicum of rest, it is with great difficulty that he spares the 
feime or puts himself in condition to give the same care to his own 
financial interests that a merchant, a lawyer, or even a farmer devotes. 
It is then plainly apparent that a system of bookkeeping and accounts- 
that, without sacrificing accuracj^, but, on the other hand, ensuring it, at 
the same time relieves the keeping of a physician's book of half their 
complexity and two-thirds the labor, is a convenience which will be 
eagerly welcomed by thousands of overworked physicians. Such a sys- 
tem has at last been devised, and we take pleasure in offering it to the 
profession in the form of The Physician's All-Requisite Time- and 
Labor- Saving Account-Book. 

There is no exaggeration in stating that this Account-Book and 
Ledger reduces the labor of keeping your accounts more than one-half^ 
and at the same time secures the greatest degree of accuracy. We may 
mention a few of the superior advantages of The Physician's All- 
Requisite Time- and Labor- Saving Account-Book, as follow: — 



First— ^\\\ meet all the requirements of ] 
the h\w and courts. I 

Second — Self-explanatory ; no cipher code. \ 
Third — Its completeness without sacrificing 

anything. I 

Fourth — No posting ; one entry only. i 

Fifth — Universal ; can be commenced at any j 

time of year, and can be continued in- ! 

definitely until every account is filled. j 

Sixth — Absolutely no waste of space. j 

Seventh — One person must needs be sick 

every day of the year to fill his account, j 

or might be ten years about it and re- | 

quire no more than the. space for one j 

account in this ledger. j 

Eighth — Double the number and many times 

more than the number of accounts in ' 



any similar book ; the 300-page book 
contains space for 900 accounts, and the 
600-page book contains space for 180(> 
accounts. 

Ninth — There are no smaller spaces. 

Tenth — Compact without sacrificing com- 
pleteness ; every account complete on 
same page — a decided advantage and 
recommendation. 

Eleventh — Uniform size of leaves. 

Twelfth — The statement of the most com- 
plicated account is at once before you 
at any time of month or year — in other 
words, the account itself as it stands is 
its simplest statement. 

Thirteenth — No transferring of accounts, 
balances, etc. 



To all physicians desiring a quick, accurate, and comprehensive 
method of keeping their accounts, we can safely say that no book a& 
suitable as this one has ever been devised. 



NET PRICES, SHIPPING EXPENSES PREPAID. 

No. 1. 300 Pages, for 900 Accounts per Year, Canada Great 

. Size 10x13, Bound in % Russia, Raised I" U. S. (duty paid). Britain. France. 

Back-Bands, Cloth Sides, . . . ^5.00 S5.50 £0.18s. 30 fr. 30 
No. 2. 600 Pages, for 1800 Accounts per Year, 

Size 10x13, Bound in % Russia, Raised 

Back-Bands, Cloth Sides, . . . 8.00 8.80 1.13s. 49 fr. 40 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) n 



PHYSICIANS' INTERPRETER 

IN FOUR LANGUAGES. 

(ENGLISH, FRENCH, GERMAN, AND ITALIAN.) 



especially Arrang^ed for Oias:nosis by M. von V. 



The object of this little work is to meet a need often keenly felt by 
the busy physician, namely, the need of some quick and reliable method 
of communicating intelligibly with patients of those nationalities and 
languages unfamiliar to the practitioner. The plan of the book is a sys- 
tematic arrangement of questions upon the various branches of Practical 
Medicine, and each question is so worded that the only answer required 
of the patient is merely Yes or No. The questions are all numbered, 
a,nd a complete Index renders them always available for quick reference. 
The book is written by one who is well versed in English, French, Ger- 
man, and Italian, being an excellent teacher in all those languages, and 
who has also had considerable hospital experience. 



Bound in Full Russia Leather, for Carrying in the Pocket. (Size, 5x2| 

Inches.) 206 Pages. Price, post-paid, in United States and 

Canada, $1.00, net; Great Britain, 4s. 6d. ; France, 6 fr. 20. 



To convey some idea of the scope of the questions contained in the 
Physicians' Interpreter, we append the Index : — 



(ieneral health i- 50 

Special diet 31- 47 

Age of patient 52- 62 

Necessity of patients undergoing an opera- 
tion 63- 70 

Office hours ^^- 77 

Days of the week 78- 84 

Patient's history: hereditary affections in his 
family; his occupation; diseases from 

his childhood up 85-130 

Months of the year. 106-117 

Seasons of the year 118-121 

Symptoms of typhoid fever. . 131-158 

Symptoms of Bright's disease 159-168 

Symptoms of lung diseases 169-194 and 31 1-3 12 

Vertigo 195-201 

The eyes 201—232 

Paralysis and rheumatism .236-260 

Stomach complaints and chills 26 1-269 



Falls and fainting spells 271-277 

How patient's illness began, and when pa- 
tient was first taken sick 278-279 

Names for various parts of the body 283-299 

The liver 300-301 

The memory 304-305 

Bites, stings, pricks 314-316 

Eruptions 317-318 

Previous treatment 319 

Symptoms of lead-poisoning 320-384 

Hemorrhages 325-328 

Burns and sprains 330-331 

The throat 332-335 

The ears 336-339 

General directions concerning medicines, 
baths, bandaging, gargling, painting 

swelling, etc 340-373 

Numbers pages 202-204 



The work is well done, and calculated to be of great 
service to those who wish to acquire familiarity with the 
phrases used in questioning patients. More than this, we 
believe it would be a great help in acquiring a vocabulary 
to be used in reading medical books, and that it would fur- 
nish an excellent basis for beginning a study of any one of 
the languages which it includes. — Medical and Surgical 
Reporter. 

Many other books of the same sort, with more ex- 
tensive vocabularies, have been published, but, from their 
size, and from their being usually devoted to equivalents 
in English and one other language only, they have not had 
the advantage which is pre-eminent in this— convenience. 
It is handsomely printed, and bound in flexible red leather 
in the form of a diary. It would scarcely make itself felt 
in one's hip-pocket, and would insure its bearer against any 
ordinary conversational difficulty in dealing with foreign- 
speaking people, who are constantly coming into our city 
hospitals. — Neio York Medical Journal. 

In our larger cities, and in the whole Northwest, the 
physician is constantly meeting with immigrant patients, 
to whom it is difficult for him to make himself understood, 
or to know what they say in return. This difficulty will 



be greatly obviated by use of this little work.— TAe Phy- 
sician and Surgeon. 

The phrases are well selected, and one might practice 
long without requiring more of these languages than this 
little book furnishes.— P/iJ/a. Medical IHrnes. 

How oftiu the physician is called to attend those with 
whom the English language is unfamiliar, and many phy- 
sicians are thus dejirived of the means, save through an 
interpreter, of arriving at a correct knowledge on which to 
base a diagnosis. An interpreter is not alwaj's at hand, 
but with this pocket interpreter in your hand j-ou are able 
to ask all the questions necessary, and receive the answer 
in such manner that you will be able to fully comprehend. 
— The Medical Brief' 

This little vblume is one of the most ingenious aids 
to the phvsician which we have seen. We heartily com- 
mend the" book to any one who, being without a knowledge 
of the foreign languages, is obliged to treat those wlio do 
not know our own language.— S^. Louis Courier of Medi- 
cine. 

It will rapidly supersede, for the practical use of the 
doctor who cannot take the time to learn another language, 
all other suggestive works.— C/i»VM.'7o Medical Times. 



18 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



An Important Aid to Students in tlie Study of Anatomy. 
Three Charts or 

Tlie Nervo- Vascular System. 

rAJRT I.— THE JSJEUVJES. 

BABT II.—TSB ABTEUIJES. 

JPAJRT III.— THE VEINS. 

Arranged by W. HENRY PRICE, A.M., M.D., AND S. POTTS EAGLETON. 
ENDORSED BY LEADING ANATOMISTS. 



PRICE, IN THE UNITED STATES AND CANADA, 50 CENTS, NET, COMPLETE; 
GREAT BRITAIN, 2s. 6d. FRANCE, 3 fr. 60. 



THE NERVO-VASCULAR SYSTEM OF CHARTS " far Excels Every Other System 
in their Completeness, Compactness, and Accuracy. 



I^avt I. The Nerves, — Grives in a clear form not onl}' the Cranial 
and Spinal Nerves, showing the formation of the different Plexuses 
and their branches, but also the complete distribution of the 
fe^MPATHETic Nerves, thereby making it the most complete and 
concise chart of the Nervous S^'stem 3^et published. 

I^art II. The Arteries. — Gives a unique grouping of the Arterial 
Sj'stem, showing the divisions and subdivisions of all the vessels, 
beginning from the heart and tracing their continuous distribution 
to the periphery, and showing at a glance the terminal branches 
of each artery. 

I^art III. The Veins. — Shows how the blood from the periphery 
of the \)ody is gradually collected by the larger veins, and these 
coalescing forming still larger vessels, until they finally trace 
/ themselves into the Right Auricle of the heart. 

It is therefore readily seen that " The Nervo-Vascular System of 
Charts " offers the following superior advantages : — 

1. It is the onl}^ arrangement which combines the Three Systems, 
and 3'et each is perfect and distinct in itself. 

2. It is the only instance of the Cranial, Spinal, and Sympathetic 
Nervous Systems being represented on one chart. 

3. From its neat size and clear t^q^e, and being printed only upon 
one side, it ma}^ be tacked up in any convenient place, and is alwaj^s 
read}" for freshening up the memor}' and reviewing for examination. 

4. The nominal price for w^hich these charts are sold places them 
w^ithin the reach of all. 

For the student of anatomy there can possibly be no veins of the human body, si^'ing names, origins, distribu- 

more concise way of acquiring a knowledge of the 'nerves, , tions, and functions, very convenient as memorizers and 

veins, and arteries of the human system. It presents at a | reminders. A similar series, prepared by the late J. H. 

glance their trunks and branches iii the great divisions of , [ Armsby, of Albany, jST.Y., and framed, long found a place 

the body. It will save a world of tedious reading, and will \ in the study of the writer, and on more than one occasion 

impress itself on the mind as no ordinary vade mecum, \ j was the means of saving precious moments that must 

even, could. Its price is nominal and its value inestima- otherwise have been devoted to tumbling the pages of ana- 

ble. No student should be without it.— Pacific Record of '■ ! tomical works.— J/^ec/. Age. 

Medicine and Surgery. ' _,, ^, i, ^ -n v ^ 

" " .1 These three charts will be of great assistance to 

We take pleasure in calling attention to these charts, , ' medical students. They can be hung on the wall and read 

■as they are so arranged that a study of them will serve to | i across any ordinary room. The price is only fifty cents for 

impress them more indellibly on your mind than can be \' the set. — Practice. 

gained in anv other way. They are also valuable for I j „, x. ^ v v ah „»_„„„„j ..^a T.-;n 

reference.-J/ed;ca? £n>/. '! These charts have been carefully arranged, and vwll 

■' ! prove to be very convenient for ready reference, ihey 

These are three admirably arranged charts for the !; are three in number, each constituting a part. . . . . 

use of students, to assist in memorizing their anatomical h K is a high recommendation that these charts have been 

studies.— £u#a?o Mtd. and Sura. Jour. \ ' examined and approved by John B. Deaver, M.D.. Demon- 

I i strator of Anatomy in the University of Pennsylvania.— 

This is a series of charts of the nerves, arteries, and '< Pacific Med. and Surg. Jour, and Western Lancet. 



(F. A. DAVIS, Medical Publisher Philadelphia, Pa., U.S.A.) 19 



EVERY SANITARIAN SHOULD HAVE ROHliI'S "TEXT-BOOK OF HYG^IENE '» 
AS A WORK OF REFERENCE. 



SECOItTID •^JDXn?X01<T.- 



-XlsT ]PZ^ESS. 



TEXT-BOOK OF HYGIENE: 

A COMPREHENSIVE TREATISE ON THE PRINCIPLES AND PRACTICE OF PREVENTIVE MEDICINE 
FROM AN AMERICAN STAND-POINT. 

By OKORGB H. ROBEE^, ]»I.D., 

Professor of Obstetrics and Hygiene iu the College of Physicians and Surgeons, Baltimore ; Director of the Maryl»«A 

Matemite ; Member of the American Public Health Association ; Foreign Associate of the Societe Fran^aise 

d'Hygiene, of the Societe des Chevaliers-Sauveteurs des Alpes Maritimes, etc. 



Net Price, in the United States, S2.50; in Canada (duty paid), «3.75 ; in 
Great Britain, lis. 3d. ; France, 16 tr. 20. 



Second Edition — Thoroughly Revised and Largely Rewritten, with many Illustrations 
AND Valuable Tables. Rohe's Hygiene is the Standard Text-Book in many Medical Colleges in the 
United States and Canada. It is a sound guide to the most modern and approved practice in Applied 
Hygiene. This New Edition will be issued early in the Spring of 1890, in one handsome 
Octavo volume of about 400 pages, bound in Extra Cloth. Read what competent critics have said of the 
first edition of Rohe's "Text-Book of Hygiene": — 

Nothing better for the teacher, practitioner, or student. 
— Mississippi Valley Medical Monthly. 

Contains a mass of information of the utmost impor- 
tance. — Independent Practitioner. - 

Just the work needed by the medical student and th« 
tusy, active, sanitary o&Ger.— Southern Practitioner. 

This very useful work. — American Jour. Med. Sciences. 

Comprehensive in scope, well condensed, clear in style, 
and abundantly supplied with references. — Journal Amer- 
ican Medical Association. 



A storehouse of facts. — British Medical Journal. 

Of invaluable assistance to the student. — Sanitary News. 

This interesting and valuable book.— Paci^c Medical 
mnd Surgical Journal. 

Based upon sound principles and good practice.— Pi'iito- 
delphia Medical Times. 

Full of important matter, told in a very interesting 
vi&nxiQv.— Science. 

In harmony with the most recent advances in pathology. 
— Medical Times and Gazette, London. 



JX7ST ISSXTSD 



PHYSICIANS' AND STUDENTS' READY-REFERENCE SERIES 

The Neuroses of the Genito-Urinary System 

WITH STEBILITY ANJD IMJPOTEJS^CE. 



DR. R. ULTZIVIANN, 

Professor of Genito-Urinary Diseases in the University of Vienna. 
TRANSLATED, WITH THE AUTHOR'S PERMISSION, BY 

GARDNER W; ALLEN, M.D., 

Surgeon in the Genito-Urinary Department Boston Dispensary. 



Illustrated. 13mo. Handsomely Bound in Dark-Blue Cloth. Net Price, in the United 
States and Canada, .«1.00, Post-paid ; Great Britain, 4s. 6d. ; France, 6 fr. 30. 



This great work upon a subject which, notwithstanding the great strides that hav» 
been made in its investigation and the deep interest it possesses for all, is nevertheless 
still but imperfectly understood, has been translated in a most perfect manner, and pre- 
serves most fully the inherent excellence and fascinating style of its renowned and 
lamented author. Full and complete, yet terse and concise,- it handles the subject with 
such a vigor of touch, such a clearness of detail and description, and such a directness to 
the result, that no medical man wjio once takes it up will be content to lay it down until 
its perusal is complete, — nor will one reading be enough. 

Professor Ultzmann was recognized as one of the greatest authorities in his chosen 
specialty, and it is a little singular that so few of his writings have been translated into 
English. Those who have been so fortunate as to benefit by his instruction at th€ Vienna 
Polyclinic can testify to the soundness of his pathological teachings and the success of his 
methods of treatment. He approached the subject from a somewhat different point of 
view from most surgeons, and this gives a peculiar value to the work. It is believed, 
moreover, that there is no convenient hand-book in English treating in a broad manner 
the Genito-urinary Neuroses. 

SYNOPSIS OF CONTENTS. First Part.— I. Chemical Changes in the Urine iu 
Cases of Neuroses. II. The Neuroses of the Urinary and of the Sexual Organs, classi- 
fied as : 1, Sensory Neuroses ; 2, Motor Neuroses ; 3, Secretory Neuroses. Second Part, — 
Sterility and Impotence. 

The Treatment in all Cases is Described Clearly and Minutely. 



20 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



Hay Fever 



-^SlJLstz:. 



ITS SUCCESSFUL TREATMENT BY SUPERFICIAL ORGANIC 
ALTERATION OF THE NASAL MUCOUS MEMBRANE. 



CHARI.BS B. SAJOUS, m.O., 

L««*arer on Rhinology and Larrngology in JetTerson Medical College: Vice-President of the American Laryngalogical 

Association: Ofl&cer of the Academy of France and of Public Instruction of Venezuela: Corresponding 

Member of the Royal Society of Belgium, of the Medical Society of "Warsaw (Poland), 

and of the Society of Hygiene of France : Member of the American 

Philosophical Society, etc., etc. 



WITH 13 ENGRAVINGS ON \VOOD. 12mo. BOUND IN CLOTH. BEVELEl 

EDGES. PKICE, IN UNITED STATES AND CANADA, NET, Sl.OO; 

GREAT BRITAIN, 4s. 3d.; FRANCE, 6 fr. 20. 



The object of this little work is to place in the hands of the general 
practitioner the means to treat successfnlly a disease which, until lately, 
was considered as incurable ; its history, causes, pathology, and treat- 
ment are carefully described, and the latter is so arranged as to be 
practicable by an}^ phj^sician. 



Dr. Sajous' volume must command the attention of | 

tkose called upon to treat this heretofore intractable com- \ 

plaint. — jfedical and Surgical Reporter. j 

Few have had the success in this disease which has ' 

so much baffled the average practitioner as Dr. Sajous, con- | 
sequently his statements are almost authoritative. The 

fcook must be read to be appreciated. — American Medical i 

mge^t. I 

Dr. Sajous has admirably presented the suhject, and, I 

AS this method of treatment is now generally recognized i 

AS efiBcient, we can recommend this book to all physicians ! 



who are called upon to treat this troublesome disorder. — 
Tlie Buffalo Medical and Surgical Journal. 

The symptoms, etiology, pathology, and treatment of 

Hay Fever are fully and ably discussed. The reader will 

j not regret the expenditure of the small purchase price of 

this work if he has cases of the kind to treat. — California 

Medical Journal. 

We are pleased with the author's views, and heartily 
commend his book to the consideration of the professio». 
—The Southern Clinic. 



PHYSICIANS' AND STUDENTS' READY REFERENCE SERIES. 



ISTO. 1.: 



OBSTETRIC SYNOPSIS. 

By JOHN S. STEWART, M.D., 

Demonstrator of Obstetrics and Chief Assistant in the Gynaecological Clinic of the Medico-Chirurgical 

College of Philadelphia. 

WITH AN INTRODUCTORY NOTE BY 

WILLIAM S. STEWART, A.M., M.D., 

Professor of Obstetrics and Gynaecology in the Medico-Chirurgical College of Philadelphia. 



42 ILLUSTRATIONS. 202 PAGES. 12 mo. 



HANDSOMELY BOUND IN DARK-BLUE CLOTH. 

.00; 



Price, Post-paid, in the United States and Canada, Net 
Great Britain, 4s. 3d. ; France, 6 fr. 20. 



By students this work will he found particularly useful. It is hased 
upon the teachings of such well-known authors as Plaj^fair, Parvin, 
Lush, Galabin, and Cazeaux and Tarnier, and, besides containing much 
new and important matter of great value to both student and practi- 
tioner, embraces in an Appendix the Obstetrical Nomenclature sug- 
gested by Professor Simpson, of Edinburgh, and adopted by the 
Obstetric Section of the Ninth International Medical Congress held in 
Washington, D.C., September, 188T. 



It is well written, excellently illustrated, and fully up 
X* date in everj- respect. Here we find all the essentials of 
Obstetrics in a nutshell, Anatomy, Embryology, Physi- 
♦l»gy. Pregnancy, Labor, Puerperal State, and Obstetric 
Operations all being carefally and accurately described. — 
Buffalo Medical and Surgical Journal. 

It is clear and concise. The chapter on the develop- 
veat of the oTum is especially satisfactory. The judicious 



use of bold-faced type for headings, and italics for impor- 
tant statements, gives the book a pleasing typographical 
appearance. — Medical Record. 

This volume is done with a masterly kand. The 
scheme is an excellent one. . . . The whole is freely 
and most admirably illustrated with well-drawn, new 
engravings, and the book is of a very eonvenient size.— 
St. Louis Medical and Surgical Journal. 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



DIPHTHERIA: 

Croup, Tracheotomy, ts- Intubation 

FROM THE FRENCH OF A. SANNfe. 



TRANSLATED AND ENl.ARGED BY 



HKNRY Z. QILI., IM.D., LIv.E). 



United States. Canada (duty paid). Great Britain. France. 

ITet Price, Post-paid, Cloth, • -$4.00. $4.40. £ 0.18s. 24fr. 60 

Leather, - 5.00. 5.50. 1. Is. 30 fr. 30 



The above work, recently issued, is a translation from the French of Sanne's great 
work on " Diphtheria," by H. Z. Gill, late Professor of Surgery in Cleveland, Ohio. 

Sanne's work is quoted, directly or indirectly, by every writer since its publication, 
as the highest authority, statistically, theoretically, and practically. The translator,, 
having given special study to the subject for many years, has added over fifty pages, in- 
cluding the Surgical Anatomy, Intubation, and the recent progress in the branches- 
treated down to the present date; making it, beyond question, the most complete work 
extant on the subject of Diphtheria in the English language. 

Facing the title-page is found a very fine Colored Lithograph Plate of the parts con- 
cerned in Tracheotomy. Next follows an illustration of a cast of the entire Trachea, and 
bronchi to the third or fourth division, in one piece, taken from a photograph of a case 
in which the cast was expelled during -life from a patient sixteen years old. This is the 
most complete cast of any one recorded. 

Over fifty other illustrations of the surgical anatomy of instruments, etc., add to the 
practical value of the work. 

Diphtheria having become such a prevalent, wide-spread, and fatal disease, no 
general practitioner can afford to be without this work. It will aid in preventive meas- 
ures, stimulate promptness in the application of, and efficiency in, treatment, and 
moderate the extravagant views which have been entertained regarding certain specifics 
in the disease Diphtheria. 

A full Index accompanies the enlarged volume, also a List of Authors, making 
altogether a very handsome illustrated volume of over 680 pages. 



In this book we have a complete review and 
compendium of all worth preserving that has hitherto 
been said or written concerning diphtheria and the 
kindred subjects treated of by our author, collated, 
arranged, and commented on by both author and 
translator. The subject of intubation, so recently 
revived in this country, receives a very careful and 
impartial discussion at the hands of the translator, 
and a most valuable chapter on the prophylaxis of 
diphtheria and croup closes the volume. 

His notes are frequent and full, displaying deep 
knowledge of the subject-matter. Altogether the 
book is one that is valuable and timely, and one 
that should be in the hands of every general practi- 
tioner. — Si. Louis Med. and Surgical Journal. 



Sanne's work is quoted, directly or indirectly, 
by many writers since its publication, as the highest 
authority, statistically, theoretically, and practi- 
cally. The translator, having given special study 
to the subject for many years, has added over fifty 
pages, including the surgical anatomy, intubation, 
and the recent progress in the branches treated, 
down to the present date; making it, beyond ques- 
tion, the most complete work extant on the subject 
of diphtheria in the English language. Diphtheria 
having become such a prevalent, wide-spread, and 
fatal disease, no general practitioner can afford to 
be without this work. It will aid in preventive 
measures, stimulate promptness in application of, and 
efficiency in, treatment. — Southern Practitioner. 



SUmTOH'S PRACTICIIL AKD SCIEHIIFIC PHYSIOGNOMY 



By MARY OLMSTED STANTON. 



Copiously Illustrated. 



X^vo I^arsfe Octavo Volumes. 

United states. Canada (duty paid). Great Britain. France. 

Price, per Volume, Cloth, i$5.00 !S5.50 «l.ls. 30 fr. 30 

" " Sheep, 6.00 6.60 1.6s. 36 fr. 40 

" «* Half-Kussia, 7.00 7.70 1.9s. 43 fr. 30 

$1.00 Discount fok Cash. Sold only by Subscription, or sent direct on receipt of price, shipping expenses prepaid. 



The author, Mrs. Mary O. Stanton, has given over twenty years to the preparation of this work. Her 
style is easy, and, by her happy method of illustration of every point, the book reads like a novel, and 
memorizes itself. To physicians the diagnostic information conveyed is invaluable. To the general 
reader each page opens a new train of ideas. (This book has no reference whatever to Phrenology.) 



22 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



XMLFORTAJirr AJSNOXINCETHEirr. 

A TREATISE 

— ON 

Materia Medica, Pharmacology, i Therapeutics. 

BY 

dOHN \J. SHOEMAKER, A.M., M.D., 

Professor of Materia Medica, Pharmacology, and Therapeutics in the Medico-Chirurgical College of Phila- 
delphia, and Member American Medical Association, 

AND \ 

dOriN AULDE, M.D., 

Demonstrator of Clinical Medicine and of Physical Diagnosis in the Medico-Chirurgical College of Phila- 
delphia, and Member American Medical Association. 



IN TWO HANDSOME ROYAL OCTAVO VOLUMES. 

NET PRICES, per Volume, in United States: Cloth, »3.50; Sheep, S3. 35. In Canada 

(duty paid) : Cloth, «3.75 ; Sheep, $3.55. In Great Britain: Cloth, lis. 3d. ; 

Sheep, 14s. 6d. In France : Cloth, 16 fr. 20 ; Sheep, 20 fr. SO. 



THE Publisher takes pleasure in announcing that Volume I of this eagerly -looked-for 
work is Now Ready, and that the utmost diligence will be exercised in filling with 
the greatest rapidity, and in regular order of receipt, the numerous orders now awaiting 
its publication. 

The general plan of the work embraces three parts, each of which is practically inde- 
pendent of the other, as will be understood from the accompanying analysis, and of which 
Parts I and II are contained in the volume now announced ; this, however, is not the only 
advantage accruing from the preparation of the work in two volumes. Each volume will 
thus be much smaller and more convenient to handle, while some may wish to secure a 
particular portion of the work, and to them the cost is lessened. 

Several blank sheets of closely-ruled letter-paper are inserted at convenient places in 
the work, thus rendering it available for the student and physician to add valuable note& 
concerning new remedies and other important matters. 

Part I embraces three subdivisions, as follow : — 

First. A brief synopsis upon the subject of pharmacy, in which is given a clear and 
concise description of the operations and preparations taken into account by the physician 
when prescribing medicines, together with some practical suggestions regarding the most 
desirable methods for securing efficiency and palatability. 

Second. A Classification of Medicines is presented under the head of " General Phar- 
macology and Therapeutics," with a view to indicate more especially the methods by 
which the economy is affected. Thus, there are Internal and External Remedies, and, 
besides, a class termed Chemical Agents, including Antidotes, Disinfectants, and Anti- 
septics, and an explanatory note is appended to each group, as in the case of Alteratives, 
Antipyretics, Antispasmodics, Purgatives, etc. 

Third. A Summary has been prepared upon Therapeutics, covering methods of 
Administration, Absorption and Elimination, Incompatibility, Prescription-writing, and 
Dietary for the Sick, this section of the work embracing nearly one hundred and fiftv 



Part II is devoted to "Remedies and Remedial Agents Not Properly Classed with 
Drugs," and includes elaborate articles upon the following topics : Electro-Therapy, 
Hydro-Therapy, Masso-Therapy, Heat and Cold, Oxygen, Mineral -Waters, and, in addi- 
tion thereto, other subjects, perhaps of less significance to the practitioner, such as Clima- 
tology, Hypnotism and Suggestion, Metallo-Therapy, Transfusion, and Baunscheidtismus, 
have received a due share of attention. This section of the work embraces over two hun- 
dred pages, and will be found especially valuable to the student and recent graduate, as 
these articles are fully abreast of the times. 

Volume II, which is Part III of the work, is wholly taken up with the consideration 
of drugs, each remedy being studied from three points of view, viz., the Preparations, or 
Materia Medica; the Physiology and Toxicology, or Pharmacology, and, lastly, its 
Therapy. It will be Ready about May 1, 18'90. 

The typography of the work will be found clean, sharp, and easily read without 
injury to the visual organs, and the bold-face type interspersed throughout the text makes 
the different subjects discussed quick of reference. The paper and binding will also be up 
to the standard, and nothing will be left undone to make the work first-class in every 
particular, 

(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S A.) 23 



JUST PUBLISHED.: 



THE PHYSIOLOGY 

OF THE 

Domestic Animals. 

A TEXT-BOOK FOR VETERINARY AND MEDICAL 
STUDENTS AND PRACTITIONERS. 

— BY— 

ROBERT MEADE SMITH, A.M., M.D., 

Professor of Comparative Physiology in University of Pennsylvania ; Fellow of the College of Physiciaas 

and Academy of the Natural Sciences, Philadelphia ; of the American Physiological 

Society ; of the American Society of Naturalists ; Associe Etranger 

de la Societe Frangaise D' Hygiene, etc. 




Fig. 117. — Parotid and Submaxillary Fistul^e in the Horse, after Colin. 

{Thanhoffer and Torrnay.) 
K, K', rubber bulbs for collecting saliva ; cs, cannula in the parotid duct. 



In One Handsome Royal Octavo Volume of over 950 Pages, Pro- 
fusely Illustrated -with more than 400 Fine "Wood- 
Engravings and many Colored Plates. 

United States. Canada (duty paid). Great Britain. France. 

NET PRICES, CLOTH, $5.00 $5.50 ^1. 30 fr, 30. 

SHEEP, 6.00 6.60 1.6. 36 fr. 20. 



nrmS new and important work, the most thoroughly complete in the English language 
on this subject, has just been issued. In it the physiology of the domestic animals 
is treated in a most comprehensive manner, especial prominence being given to the sub- 
ject of foods and fodders, and the character of the diet for the herbivora under different 
conditions, with a full consideration of their digestive peculiarities. Without being over- 
burdened with details, it forms a complete text-book of physiology, adapted to the use of 
students and practitioners of both veterinary and human medicine. This work has already 
been adopted as the Text-Book on Physiology in the Veterinary Colleges of the United 
States, Great Britain, and Canada. 



24 (F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



Ab5TRACT5 FROn Reyiew5=^*3mith'5 FhY510L0QY. 



^^ 



:!^- 



The work throughout is well balanced. 
Broad, though not encyclopaedic, concise 
without sacrificing clearness, it combines 
the essentials of a successful text-book, it 
is eminently modern, and, although first in 
the field, is of such grade of excellence that 
snccessors must reach a high standard be- 
fore tliey become competitors. — Annals of 
S^irgery. 

Dr. Smith has conferred a great benefit 
upon the veterinary profession by his con- 
tribution to their use of a work of immense 
value, and has provided the American vet- 
erinary student with the only means by 
which he can become properly familiar with 
the physiology of our domestic animals. 
Veterinary practitioners and graduates will 
read it with plea?;ure. Veterinary students 
will readily acquire needed knowledge from 
its pages, and veterinary schools which 
would oe well equipped for the work they 
aim t-o perform cannot ignore it as their 
text-book in physiology.— .A7nerican Veteri- 
nary Review. 

Dr. Smith's presentment of his subject 
is as brief as the status of the science per- 
mits, and to this much-desired conciseness 
he has added an eq^ually welcome clearness 
of statement. The illustrations in the work 
are exceedingly good, and must prove a 
valuable aid to the full understanding of 
the text. — Journal of Comparaiive Medicine 
and Surgery. 

"We have examined the work in a great 
many particulars, and find the views so 
correct, where we have had the means of 
comparison of statements with those of some 
recognized authority, that we will be com- 
pelled hereafter to look to this work as the 
t-ext-book on physiology of animals. The 
book will prove of incalculable benefit to 
veterinarians wherever they may be found; 
and to the country physician, who is often 
called upon to attend to sick animals as 
well as human beings, we would say, lose 
no time in getting this work and let him 
familiarize himself with the facts it con- 
tains. — Virginia Medical Monthly. 

Altogether, Professor Smith's '■ Physi- 
ology of the Domestic Animals" is a happy 
production, and will be hailed with delight 
in both the human medical and veterinary 
medical worlds. It should find its place 
besides in all agricultural libraries. — Paul 
PAQUiir, M.D., V.S., in the Weekly Me.lical 
Review. 

It may be said that it supplies to the 
veterinary student the place in physiology 
that Chauveau's incomparable work — " The 
Comparative Anatomy of the Domesticated 
AnimaLg" — occupies in anatomy. Higher 
praise than this it is not possible to bestow. 
And since it is true that the same laws of 
physiology which are applicable to the vital 
process of the domestic animals are also ap- 
plicable to man, a perusal of this carefully 
written book will repay the medical student 
or practitioner. — Canadian Practitioiier . 



The work before us fills the hiatus of 
which complaint, has so often been made, 
and gives in the compass of less than a 
thousand pages a very full and complet<i 
account of the functions of the body in both 
carnivora and herbivora. The author has 
judiciously made the nutritive functions the 
strong point of the work, and has devoted 
special attention to the subject of foods and 
digestion. In looking through the other 
sections of the work, it appears to us that a 
just proportion of space is assigned to each, 
in view of their relative importance to the 
practitioner. Thus, while the subject of re- 
production is dismissed in a few pages, a 
chapter of considerable length is devoted 
to locomotion, and especially to the gaits of 
the horse. — London Lancet. 

This is almost the only work of the kind ' 
in the English language, and it so fully 
covers every detail of general and special 
physiology that there is no room for any 
rival. The excellence of typographical 
work, and the wealth, beauty, and clear- 
ness of the illustrations, correspond with 
the thoroughness and clearness of the 
treatise. — Albany Medical Annals. 

It is not often that the medical profes- 
sion has the opportunity of reading a new 
book upon a new subject, and doubtless 
English-speaking physicians will feel grate- 
ful to Professor Smith for his admirable 
and pioneer work in a branch of medical 
science upon which a great amount of ignor- 
ance prevails. . . . The last portion of 
the work is devoted to the reproductive 
functions, and contains much valuable in- 
formation upon a portion of animal physi- 
ology concerning which many are ignorant. 
The book is a valuable one in every way, 
and will be consulted largely by veterinary 
and medical students and practitioners. — 
Buffalo Medical and Surgical Journal. 

The appearance of this work is most op- 
portune. It will be much appreciated, as 
tending to secure the thorough comprehen- 
sion of function in the domesticated ani- 
mals, and, in consequence, their general 
well-being — a matter of world-wide impor- 
tance. With a thorough sense of gratifica- 
tion we have perused its pages : throughout 
we find clear expression, clear reasoning, 
and that patient accumulation of facts so 
valuable in a text-book for students. — 
British MedicoJ. Journal. 

For notice this time, I take up the vol- 
ume on the " Physiology of the Domestic 
Animals." by Dr. R. Meade Smith, a volume 
of 938 pages, closely printed, and dealing 
with its subject in a manner sufficiently ex- 
haustive to insure its place as a text-book 
for fifteen years at the very least. Its 
learning is only equaled by its industry, 
and its industry by the consi.'^teney and 
skill with winch its varied parts are brought 
together into harmonious, lucid, and in- 
tellectual unity. — De. Benjami??- Waed 
RiCHAEDSON, in the London Asclepiod. 

— S ^ 



CF. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



International Foeket Msdieal FopmulaPi 

ARRANGED THERAPEUTICALLY. 

By G. SUMNER WlTHERSTlNE, M.S., M.D., 

Associate Editor of the "Annual of the Universal Medical Sciences;" Visiting Physician of the Home for 
the Aged, Germantown, Philadelphia; Late House-Surgeon Charity Hospital, New York. 

More than 1800 Formu/ce from Several Hundred Well-Known Authorities. 

With an Appendix containing a Posological Table, the newer remedies included ; Important Incorapati- 
bles ; Tables on Dentition and the Pulse ; Table of Drops in a Fluidrachm and Doses of Laudanum graduated 
for age ; Formulae and Doses of Hypodermic Medication, including the newer remedies; Uses of the Hypo- 
dermic Syringe; Formulae and Doses for Inhalations, Nasal Douches, Gargles, and Eye-washes; Formulae 
for Suppositories; Use of the Thermometer in Disease; Poisons, Antidotes, and Treatment ; Directions for 
Post-Mortem and Medico-Legal Examinations ; Treatment of Asphyxia, Sun-stroke, etc. ; Anti-emetic 
Remedies and Disinfectants; Obstetrical Table; Directions for Ligation of Arteries ; Urinary Analysis; 
Table of Eruptive Fevers : Motor Points for Electrical Treatment, etc., etc. 



This work, the best and most complete of its kind, contains about 275 printed pages, besides 
exti'a blank leaves. Elegantly printed, with red lines, edges, and borders ; with illustrations. Bound 
in leather, Avitli side flap. It contains more than 1800 Formulae, exclusive of the large amount of 
other very valuable matter. 

Price, Post-paid, in the United States and Canada, $2.00, net ; 
Great Britain, 8s. 6d. ; France, 12 fr. 40. 



TPM RFA^nN<^ ^HY EVERY MEDICAL MAN SHOULD POSSESS A COPY OF 

I cix nctiouno the international pocket medical formulary. 

1. Because it is a halndy book of reference, replete with the choicest formulae (over 1800 in number) of 
more than six hundred of the most prominent classical writers and modern practitioners. 

3. Because the remedies given are not only those whose efficiency has stood the test of time, but aiso the 
newest and latest discoveries in pharmacy and medical science, as prescribed and used by the best- 
known American and foreign modern authorities. 

3. Because it contains the latest, largest (66 formulae) and most complete collection of hypodermic formulae 

(including the latest new remedies) ever published, with doses and directions for their use in over 
fifty different diseases and diseased conditions. 

4. Because its appendix is brimful of information, invaluable in office work, emergency cases, and the 

daily routine of practice. 

6. Because it is a reliable friend to consult when, in a perplexing or obstinate case, the usual line of treat- 
ment is of no avail. (A hint or a help from the best authorities, as to choice of remedies, correct 
dosage, and the eligible, elegant, and most palatable mode of exhibition of the same.) 

6. Because it is compact, elegantly printed and bound, well illustrated, and of convenient size and shape 

for the pocket. 

/» 

7. Because the alphabetical arrangement of the diseases and a thumb-letter index render reference rapid 

and ea.sy. 

8. Because blank leaves, judiciously distributed throughout the book, aftord a place to record and index 

favorite formulae. 

9. Because, as a student , he: needs it for study, collateral reading, and for recording the favorite prescriptions 

of his professors, in lecture and clinic ; as a recent graduate, he needs it as a reference hand-book for 
daily use in prescribing (gargles, nasal douches, inhalations, eye-washes, suppositories, incompatibles, 
poisons, etc.) ; as an old practitioner, he needs it to refresh his memory on old remedies and combi- 
nations, and for information concerning newer remedies and more modern approved plans of treatment. 

10. Becaiuse no live, progressive medical man can afford to be without it. 



It is sometimes important that such prescriptions as 
have been well estaWJshed in their usefulness be preserved 
for reference, and this little volume serves such a purpose 
better than any other we have seen.— Coiamftus Medical 
Journal. 

Without doubt this book is the best one of its class 

that we have ever seen The printing, binding. 

and general appearance of the volume are beyond praise. — 
University Medical Maf/azine. 

It may be possible to get more crystallized kiiowledge 
in an equally small space, but it does not seem probable.— 
MeAical C/as-iics. 

A very handy aud valuable book of formulse for the 
physician's pocket.— «. Louis Medical and Surg. Journal. 

This little pocket-book contains an immense number 
of prescriptions taken from high authorities in this and 
other countries. — Northwestern Lancet. 

This one is the most complete as well as the most 
conveniently arranged of any that have come under our 
attention. "The diseases are enumer.ated in alphabetical 
order, and for each the latest and most approved remedies 
from the ablest authorities are prescribed. The book is in- 
dexed entirely through after the order of the first pages of 
a ledger, the index letter being printed on morocco leather 
and tliereby made very durable.— Pwrj^c MeAical Journal. 

Itiaa'book desirable for the old practitioner and for 
his vounger brothers as well.— -S<. .Toseph Mediial Herald. 



As long as "combinations" are sought such a hook 
will be of value, especially to those who cannot spare the 
time required to learn enough of incompatibjlitit^s before 
commencing practice to avoid writing incompatible and 
dangerous prescriptions. The constant use of such a book 
by such prescribers would save the pharmacist much 
unyiKty.— The Druqqists' Circular. 

In judicious selection, in accurate nomenclature, in 
arrangement, and in style it leaves nothing to be desired. 
Tlie editor and the publisher are to becongratulatetl on tlii> 
production of the very best book of its class.— Pj/fcf'x'i'//' 
Medical Review. 

One must see it to realize how much information cin 
be got into a work of so little bulk.— r«>i«</a MfdirtiL 
Record. 

To the voung physician just starting out m pract-c- 
this little book will" prove an acceptable companion.— 
Omaha Clinic. . 

The wantof to-dav is crystallized knowledge, llns 
neat little volume contains in it the most accessible form. 
It is bound in morocco in pocket form, with alphabetical 
divisions of diseases, so tliat it is possible to turn instantlv 
to the remedy, whatever may bo the disorder or whei-eyer 

the patient may be situated To the physician 

it is invaluable, and others should not be without it. We 
heartily commend the work to our readei-s.— .»f»n)i''.'<"'rt 
Medical Journal. 



26 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa.. U.S. A 



JXJST ISSXJED- - - 

PHYSICIANS' AND STUDENTS' READY-REFERENCE SERIES. 

I^To. 3. 

Synopsis of Human Anatomy 

Being a Complete Oompend of Anatomy, including- the 
Anatomy of the Viscera, and Numerous Tables. 



JAMES K. YOUNG, M.D., 

Instructor in Orthopaedic Surgery and Assistant Demonstrator of Surgery, University of Pennsylvania; 
Attending Orthopaedic Surgeon, Out-Patient Department, University Hospital, etc. 



ILLUSTRATED WITH 76 WOOD-ENGRAVINGS. 390 PAGES. 

12 mo. HANDSOMELY BOUND IN DARK-BLUE CLOTH. 

Price, Post-paid, in the United States and Canp.da, $1.40, net ; 
Great Britain, 6s. 6d. ; France, 9 fr. 25. 



While the author has prepared this work especiall}' for students, sufficient de- 
scriptive matter has been added to render it extremely valuable to the busy practitioner, 
particularly the sections on the Viscera, Special Senses, 
and Surgical, Anatomy. 

The work includes a complete account of Osteology, 
Articulations and Ligaments, Muscles, Fascias, Vascular 
and Nervous Systems, Alimentary, Vocal, and Respiratory 
and Genito-Urinarv xA.pparatuses, the Organs of Special 
Sense, and Surgical Anatomy. 

In addition to a most caretully and accurately prepared 
text, wherever possible, the value of the work has been 
enhanced bV tables to facilitate and minimize the labor of 
students in acquiring a thorough knowledge of this impor- 
tant subject. The section on the teeth has also been 
especially prepared to meet the requirements of students 
of Dentistry. 

In its preparation. Gray's Anatomy [last edition], 
edited by Keen, being the anatomical work most used, has 
been taken as the standard.- 




Anatomy is a theme that allows such concen- 
tration better than most medical subjects, and, as 
the accuracy of this little book is beyond question, 
its value is assured. As a companion to the dis- : 
secting-table, and a convenient reference for the \ 
practitioner, it has a definite field of usefulness. — j 
PittsbiirgJi Medical Review. \ 

This is a very carefully prepared compend of . 
anatomy, and will be useful to students for college ' 
or hospital examination. There are some excellent 
tables in the v/ork, particularly the one showing the ; | 
origin, course, distribution, and fimctions of the li 
cranial nerves. — Medical Record. ; 

Dr. Young has compiled a very useful book. 
We are not inclined to approve of compends as a 
general rule, but it certainly serves a good purpose 
to have the subject of anatomy presented in a com- 
pact, reliable way, and in a book easily carried to 
the dissecting-room. This the author has done. 
The book is well printed, and the illustrations well , 
selected. If a student can indulge in more than one \ 
work on anatomy, — for, of course, he must have a ! 
general treatise on the subject, — he can hardly do 
'better than to purchase this compend It will save 
the larger work, and can always be with him during 
the hours of dissection. — Buffalo Medical and \\ 
Surgical yournal. |; 



Excellent tables have been arranged, which 
tersely and clearly present important anatomical 
facts, and the book will be found very convenient 
for ready xQ{&xQx\c&.—Cobc7>ibus Medical Journal. 

The book is much more satisfactory than the 
"remembrances" in vogue, and yet is not too cimi- 
bersome to be carried around and read at odd 
moments — a property which the student will readily 
appreciate. — Weekly Medical Review. 

If a synopsis of human anatomy may serve a 
purpose, and we believe it does, it is very important 
that the synopsis should be a good one. In this 
respect the above work may be recommended 3.s a 
reliable guide. Dr. Young has shown excellent 
judgment in his selection of illustrations, in the 
numerous tables, and in the cla.ssification of the 
various subjects. — 7y/d?ra/('/<i'/c Gazette. 

Every unnecessary word has been excluded, out 
of regard to the very limited time at the medical 
student's disposal. It is also good as a reference 
book, as it presents the facts about which he wisiies 
to refresh his memory in the briefest manner 
consistent with clearness. — New York Medical 
Journal. 

It is certainly concise and accurate, and should 
be in the hands of every student and practitioner. — 
The Medical BrieJ'. 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



ANNUAL 



Universal Medical Sciences. 

A YEARLY REPORT OF THE PROGRESS OF THE GENERAL SANITARY 
SCIENCES THROUGHOUT THE WORLD. 

Edited by CHABLES E. SAJOUS, M. D., 

LECTKRER ON LARYNGOLOGY AND RHINOLOGY IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, ETC.. 

AND 

SEVENTY ASSOCIATE EDITORS, 

Assisted by over TWO HUNDRED Corresponding Editors and Collaborators. 

In Five Royal Octavo Volumes of about 500 pages each, hound in Cloth and HaJf-Enssin, 
Magnificently Illustrated with Chromo- Lithographs, Engravings. 
Maps, Charts, and Diagrams. 
BKI^G IBf XENOED =^=* 

1st. To assist the busy practitioner in his efforts to keep abreast of the rapid strides 
of all the branches of his profession. 

Sd. To avoid for him the loss of time involved in searching for that which is new in 
the profuse and constantly increasing medical literature of our day. 

3d. To enable him to obtain the greatest possible benefit of the limited time he is 
. able to devote to reading, by furnishing him with new matter only. 

4th. To keep him informed of the work done by all nations, including many other- 
wise seldom if ever heard from. 

5th. To farnish him with a review of all the new matter contained in the periodicals 
to which he cannot (through their immense number) subscribe. 

6th. To cull for the specialist all that is of a progressive nature in the general and 
special publications of all nations, and obtain for him special reports from countries in 
which such publications do not exist, and 

Lastly, to enable any physician to possess, at a moderate cost, a complete 

CONTEMPORARY HISTORY OF UNIVERSAL MEDICINE, 

edited by many of America's ablest teachers, and superior in every detail, of print, paper, 
binding, etc., etc., a befitting continuation of such great works as " Pepper's System of 
Medicine," "Ashhurst's International Encyclopedia of Surgery," " Buck's Reference 
Mand-Book of the Mfedical Sciences," etc.. etc. 



IDITORIAL STAFF of the ANNUAL of the UNIVERSAL MEDICAL SCIENCES. 

ISSUK OK x888. 
Chief Editor, DK. CHAKI.ES E. SAJOUS, Pliiladelpliia 

Volume I. — Obstetrics, Oyncecology, Pediatrics, Anatomy, Physiology, Pathology, 
Histology, and Embryology. 

P]f©f. Wm. L. Richardson, Boston. ' Prof. William Goodell and Dr. W. C. | Prof. H. Newell Martin and Dr. W. H. 
Piof. Theophilns Parvin, Philada. Goodell. Philadelphia. Howell. Baltimore. 

Prof. Louis Starr, Philadelphia. ' Prof. E. C. JDudley, Chicago. ' ~ -- 

Prof. J. Lewis Smith, New York City. Prof. W. H. Parish, Philadelphia^. 

Prof. Paal F. Munde and Dr. E. H. I Prof. William S. Forbes, Philadelphia. 

Orandin, New York City. i 

Volume II. — Diseases of the Respiratory, Circulatory, Digestive, and Nermus 
Fevers, Exanthemata, etc., etc. 



Dr. Chas. S. Mi not, Boston. 

Dr. E. O. Shakespeare, Philadelphiji 

Dr. W. X. Sudduth, Philadelphia. 



Prof. A. L. Loomis, New York City. 
Prof. Jafi. T. Whittaker, Cincinnati. 
Prof. W. H. Thomson, New York City 
Prof. W. W. Johnston, Washington. 
Prof Jos. Leidy, Philadelphia. 



Prof. E. C. Seguin, New York City. I Prof. Jas. Tvson, Philadelphia. 
Prof. E. C. Spitzka, New York Citv. Prof. N. S. bavis. Chicago. 

Prof.Chas.K. Mills and Dr. J. H.Hoyd, ; Prof. John Guit^ras, Charleston, S. C. 
Philadelphia. Dr. J.as. C. Wilson. Philadelphia. 



Prof. Francis Delafield, N. Y. City. 

Volume III. — General Surgery, Venereal Diseases, Anaesthetics, Stirgical Dres»i7igs, 

Dietetics, etc., etc. 



Prof. F. R. Sturgis, New York Citv. Prof. T. G. Morton and Dr. Wm. Hunt, 

Prof. N. Senn, Milwaukee. " Philadelphia. 



Prof. D. Hayes Agnew, Philadelphia. 
Prof. Hunter McGuire, Richmond. 
P*rof. Lewis A. Stirason, New York. 
Prof. P. S. Conner, Cincinnati. 
Prof. J. EwingMears, Philadelphia. 
l*rof. B. L. Keyes, New York City. [ 

Volume rV. — Ophthalmology, Otology, Laryngology, Rhinology, Dermatology, Dentistry^ 
Hygiene, Disposal of the l)ead, etc., etc. 



Prof. J. E. Garretson, Philadelphia. Dr. Morris Long3ti>eth, Philadelphia. 

Prof. Christopher Johnston, Baltimore. ! Dr. Chas. Wirgman. Philadelphia. 
Dr. Chas. B. Kelsey, New York City. ' Dr. C. C. Davidson. Philadelphia. 



Prof. William Thomson, Philadelphia. 
l^f. J. Solis Cohen, Philadelphia. 
Prof. D. Bryson Delavan, New York. 
Prof. A. Van Harlingen, Philadelphia. 

28 



Prof. C. N. Peirce, Philadelphia. | Dr. Chas. S. Turnbull. Philadelphia. 

Prof. John B. Hamilton, Washington. I Dr. Edw. C. Kirk, Philadelphia. 

Prof. H. M. Lyman, Chicago. ; Dr. John G. Lee, Philadelphia. 
Prof. S. H. Guilford, Philadelphia. Dr. Chas. E. Sajous, Philadelphia. 



lAst of Collaborators to Dental I)q)artmeni. 

Prof. James Truman. PKiladelphia. ■ Prof. E. H. Angle, Minneiip<5lis, Minn. Dr. J. D. Patterson. Kansas City, Sis. 

Prof. J. A. Marshall, Chicago, 111. Prof. J. E. Cravens, ludiauapolis, Ind. Dr. J. B. Uodgkin, Washington. D. C. 

Prof. A. W. Harlan. Chicago, 111. Prof. R. Stubbletield, Nashville. Tenn. Dr. R. R. Andrews, Cambridge, MaM. 

Prof. G. V. Black, Chicago, 111. Prof. W. C. Barrett, Buffalo, N. Y. Dr. Albion M. Dudlej, Salem, Mass. 

Prof. C. H. Stowell, Ann Arbor, Mich, j Prof. A. H. Thompson, Topeka, Kan. Dr. Geo. S. Allen, New York City. 

Prof. L. C. Ingersoll, Keokuk, Iowa. Dr. James W. White, Philadelphia. Dr. G. S. Dean, San Franciflco, CJal. 

Prof. F. J. S. Gorgas. Baltimore. Md. Dr. L. Ashley Faught. Philadelphia. Dr. M. II. Fletcher, Cincinnati. Ohio. 

Prof. H. A. Smith, Cincinnati. Ohio. Dr. Robert S. Ivy, Philadelphia. Dr. A. Morsman, Omaha, Neb. 

Prof. C. P. Pengra, Boston. Mass. Dr. W. Storer How, Philadelphia. Dr. G. W. Melotte. Ithaca. N. Y. 

Volume V, — General and Experimental Therapeutics, Medical Chemistry, Medical 
Jurisprudence, Demography , Climatology, etc., etc. 

Prof. William Pepper, Philadelphia. i Prof. George H. Rohe, Baltimore. Dr. W. P. Manton, Detroit, Itiok. 

Prof. F. W. Draper, Boston. I Dr. Albert L. Gihon, U. S. N. I Dr. Hobart A. Hare, Philadelphia. 

Prof. J. W. Holland, Philadelphia. | Dr. R. J. Dunglison, Philadelphia. ! Dr. C. S. WithersUne, PhUaiklpbia. 

Prof. A. L. Rauney, New York City. i 

(Including the "SATELLITE" for one year). 

United States. Canada (duty paid). Great Britain. Fra»oe. 

Cloth, 5 Vols., Royal Octavo, - - ;i»15.00 4»16.50 £3.6s. 93 fr, 95 

Half-Rusaia, 5 Vols., Royal Octavo, - 20.00 22.00 4.6s. 124 fr. 35 



EXTRACTS FROM REV/IEWS. 

We venture to say that all who saw the Annual as it appeared in 1888 were on the 
lookout for its reappearance this (1889) year; but there are many whose knowledge of this 
magnificent undertaking will date with this present issue, and to those a mere examina- 
tion of the work will suffice to sho"w that it fills a legitimate place in the evolution of 
knowledge, for it does what no single individual is capable of doing. 

These volumes make readily available to the busy practitioner the best fruits of 
medical progress for the year, selected by able editors from the current literature of the 
world; such a work cannot be overlooked by anyone who would keep abreast of the 
times. With so much that is worthy of notice incorporated in one work, and each depart- 
ment written up with a minuteness and thoroughness appreciated particularly by the 
specialist, it would avail nothing to cite particular instances of progress. Let it be sufli- 
eient to say, however, that while formerly there was a possible excuse for not having the 
latest information on matters pertaining to the medical sciences, there can no longer be 
such an excuse while the Annual is published. — Journal of the American Medical 
Association. 

We have before us the second issue of this Annual, and it is not speaking too 
strongly when we say that the series of five volumes of which it consists forms a most 
important and valuable addition to medical literature. 

Great discretion and knowledge of the subjects treated of are required at the hands 
of those who have taken charge of the various sections, and the manner in which the 
gentlemen who were chosen to fill the important posts of sub-editors have acquitted 
themselves fully justifies the choice made. We know of no branch of the profession to 
which this Annual could fail to be useful. Dr. Sajous deserves the thanks of the whole 
profession for his successful attempt to facilitate the advance of medical literature and 
practice. — London Lancet. 

This very valuable yearly report of the progress of medicine and its collateral 
sciences throughout the world is a work of very great magnitude and high importance. 
It is edited by Dr. C. E. Sajous, assisted, it is stated, by seventy associate editors, whose 
names are given, making up a learned and most weighty list. Their joint labors have 
combined to produce a series of volumes in which the current progress throughout the 
world, in respect to all the branches of medical science, is very adequately represented. 
The general arrangements of the book are ingenious and complete, having regard to 
thoroughness and to facility of bibliographical reference. — British Medical Journal. 



ANNUAL, 1890. 

The editor and publishers of the Annual of the Universal 
Medical Sciences take this opportunity to thank its numerous friends 
and patrons for the liberal support accorded it in the past, and to 
announce its publication, as usual, in 1890. Recording, as it does, the 
progress of the world in medicine and surgery, its motto continues to 
be, as in the past, " Improvement," and its friends may rest assured that 
no effort will be spared, not only to maintain, but to surpass, the high 
standard of excellence already attained. 

The Subscription Price will be the same as last year's issue and 
the issue of 1888. 

(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 29 



— ISSUE; OK 1889 



The Annual of ttie Dniversal Medical Sciences. 

In Five Koyal Octavo Volumes of over 500 pages each, bound in Clotli aii<l 

Half-Kussia, Magnificently Illustrated witli Chromo-Litliograpiis, 

Kngravings, Maps, Charts, and Diagrams. 

THE SUBSCRIPTION PRICE (including the "Satellite" for one year). 

United states. Canada (duty paid). Gi-eat Britain. France. 

Cloth, 5 Vols., Royal Octavo, - - $15.00 $16.50 £3.6s. 93fr. 95 

Half-Russia, 5 Vols., Royal Octavo, - 20.00 22.00 4.6s. 124 fr. 35 

This work is bound in above styles only, and sold by subscription. 

Published in Connection with the Annual and for Subscribers Only. 

THE SATELLITE 

OF J HE 

ANJ^UAI^ OK THK UIVIVKK-SAI^ MEOICAI, SCIKB(CHS. 

A Monthly Review of the most important articles upon the practical branches of medicine appearing in 
the medical press at large, edited by the Chief Editor of the Annual and an able staff. 



Editorial Staff of the Annual of the Universal Medical Sciences, issue of 1889- 

Chief Editor, Dr. OH AS. E. SAJOUS, Philadelphia. 

jOlSSOCIjRlTE; STjCtir*!!". 
Volume I. — Diseases of the Lungs, Diseases of the Heart, Diseases of the Gastro- 
Hepatic System, Diseases of the Intestines, Intestinal Entozoa, Diseases of 
the Kidneys and Bladdei% Fevers, Fevers in Children, Diphtheria, Rheu- 
matism and Gout, Diabetes, Volume Index. 



Praf. Jas. T. Whittaker, Cincinnati. 
Prof. A. L. Loomis, New York City. 
Prof. E. T. Bruen, Philadelphia. 
Prof. W. W. Johnston, Washington. 
Dr. L. Emmett Holt, New York. 
Prof. Jos. Leidy, Philadelphia. 



Dr. Jas. C. Wilson, Philadelphia. 
Prof. Louis Starr, Philadelphia. 
Prof. J. Lewis Smith, New York. 
Prof. N. S. Davis, Chicago. 
Prof. Jas. Tyson, Philadelphia. 



Volume II. — Diseases of the Brain and Cord, Peripheral Nervous System, Mental 
Diseases, Inebriety, Diseases of the Uterus, Diseases of the Ovaries, Diseases 
of the External Genitals in Women, Diseases of Pregnancy, Obstetrics, Dis- 
eases of the Newborn, Dietetics of Infancy, Growth, Volume Index. 

Prof. E. C. Seguin, New York City. 

Prof. Henry Hun, Albany. 

Dr. E. N. Brush, Philadelphia. 

Dr. W. R. Birdsall, New York. 

Prof. Paul F. Munde, New York City. 

Prof. Wm. Goodell, Philadelphia. 

Dr. W. C. Goodell, Philadelphia. | 

Volume III. — Surgery of Brain, Surgery of Abdomen, Genito -Urinary Surgery, Dis- 
eases of Rectum and Anus, Amputation and Resection and Plastic Surgery, 
Surgical Diseases of Circulation, Fracture and Dislocation, Military Surgery, 
Tumors, Orthopaedic Surgery, Oral Surgery, Surgical Tuberculosis, etc.. Sur- 
gical Diseases, Results of Railway Injuries, Ansesthetics, Surgical Dressings, 
Volume Index. 



Prof W. H. Parish. Philadelphia. 
Prof. Theophilus Parvin, Philadelphia. 
Prof. Wm. L. Richardson. Boston. 
Dr. A. F. Currier, New York. 
Prof. Louis Starr, Philadelphia. 
Dr. Chas. S. Minot, Boston. 



Prof. D. Hayes Agnew, Philadelphia. 
Dr. Morris Longstreth, Philadelphia. 
Dr. Thos. G. Morton, Philadelphia. 
Prof. J. E. Garretson, Philadelphia. 
Prof. J. W. White, Philadelphia. 
Prof. C. Johnston, Bfiltimore. 
Prof. E. C. Seguin, New York City. 



Prof. N. Senn, Milwaukee. 
Prof. E. L. Keyes, New York City. 
Prof. J. Ewing Mears, Philadelphia. 
Dr. Chas. B. Kelsey, New York City. 
Prof. P. S. Conner, Cincinnati. 
Dr. John H. Packard, Philadelphia 
Prof. Lewis A. Stimson, New York City. 
Dr. J. M. Barton, Philadelphia. 

'Volumie IV. — Skin Diseases, Ophthalmology, Otology, Rhinology, Diseases of Pharynx, 
etc.. Intubation, Diseases of Larynx and (Esophagus, Diseases of Thyroid 
Gland, Legal Medicine, Examination for Insurance, Diseases of the Blood, 
Urinalysis, Volume Index. 

Prof. A. Van Harlingen, Philadelphia. I Dr. Chas. E. Sajous, Philadelphia. 

Dr. Chas. A. Oliver and Dr. Geo. M. Prof. D. Bryson Delavan, New York. 

Gould, Philadelphia. , ' Prof. R. Fletcher Ingals, Chicago. 

Dr. Charles S. Turnbull, Philadelphia. Prof. F. W. Draper. Boston. 

Prof. J. Soils Cohen, Philadelphia. ; Prof. Jas. Tyson. Philadelphia. 

Prof. John Guiteras, Charleston, S. C. I 

Volume V. — General Therapeutics, Experimental Tlierapeutics, Poisons, Electric 
Therapeutics, Climatology, Dermography, Teobnology, Bacteriology, Embry- 
ology, Physiology, Anatomy, General Index. 

Dr. C. Sumner Wiiherstine, Philadelphia. \ 
Prof. J. W. Holland, Philadelphia. 
Prof. .\ L. Ranney. New York. 



Dr. J. P. Crozer Griffith, Philadelphia. 
Dr. Hobart A. Hare, Philadelphia. 
Prof Geo. H. Rohe, Baltimore. 
Prof John B. Hamilton, Washington. 
Dr. Harold C. Ernst, Boston. 
Prof. H. Newell Martin, Baltimore. 
Hr. R. J. Dunglison, Philadelphia. 



Dr. Ali)ert H. (}ihon, U. S. N. 
Dr. W. P. Manton, Detroit. 
Dr W. X. Sudduth. Philadelphia. 
Prof. Wm. r. Forbes, Philadelphia. 



(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 



THE LATEST BOOK OF EEPERENCE ON NERVOUS DISEASES, 

Lectures on Nervous Diseases, 

FROM THE STAND-POINT OF CEREBRAL AND SPINAL LOCALIZATION, AND 

THE LATER METHODS EMPLOYED IN THE DIAGNOSIS AND 

TREATMENT OF THESE AFFECTIONS. 

By /AMBROSE L. RANNEY, A.M., M.D., 

Pr J '_ssor of the Anatomy and Physiology of the Nervous System in the New York Post -Graduate Medical 

School and Hospital ; Professor of Nervous and Mental Diseases in the Medical Department of the 

University of Vermont, etc. : Author of '-The Applied Anatomy of the Nervous System," 

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With Original Diagrams and Sketches in Color by the Author, carefully selected Wood- 
Kngrravings, and Reproduced Photogjraphs of Typical Cases. 

ONE HANDSOME ROYAL OCTAVO VOLUME OF 780 PAGES. 

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It is now generally conceded that the nervous system controls all of the physn-al 
functions to a greater or less extent, and also that most of the symptoms encountered at 
the bedside can be explained and interpreted from the stand-point of nervous physiology. 

The unprecedented sale of this work during the short period which has elapsed since 
its publication has already compelled the publishers to print a second edition, which is 
already nearly exhausted. 

appeared in medical literature, is presented in com- 
pact form, and thus made easily accessible. In our 
opinion. Dr. Ranney's book ought to meet with a 
cordial reception at the hands of the medical pro- 
fession, for, even though the author's views may be 
sometimes open to question, it cannot be disputed 
that his work bears evidence of scientific method and 
honest opinion. — American yournal of Insanity. 



We are glad to note that Dr. Ranney has pub- 
lished in c::ok form his admirable lectures on nervous 
diseases. His book contains over seven hundred 
large pages, and is profusely illtistrated with origi- 
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carefully selected wood-cuts and reproduced photo- 
graphs of typical cases. A large amoimt of valua- 
ble information, not a little of which has but recently 



LKCXURES 

ON THE 

Diseases of the Nose and Throat. 

DELIVERED AT THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, 
By CHARLES E. SAdOUS, M.D., 

Lecturer on Rhinology and Laryngology in Jefferson Medical College ; Vice-President of the American Laryngological 

Association : Officer of the Academy of France and of Public Instrnctioii of Venezuela ; Corresponding Member 

of the Koyal Society of Belgium, of the Medical Society of "Warsaw (Poland), and of the Society of 

Hygiene of France ; Member of the American Philosophical Society, etc., etc. 



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Since the publisher brought this valuable work before the profession, it has become. 
1st, the text-book of a large number of colleges : 2d, the reference-book of the U. S. Army, 
Navy, and the Marine Service; and, 3d, an important and valued addition to the Ubrarieis 
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This book has not only the inherent merit of presenting a clear expose of the subject, 
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It is intended to fuinish the general practitioner 11 they would appear to him were they seen in the 

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representation of the normal and diseased parts as [■ work. — Boston Medical aud Surgical Journal. 

(F. A. DAVIS, Medical Publisher, Philadelphia, Pa., U.S.A.) 31 



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IN PRESS. SECOND EDITION, 



Ointments and Oleates In Diseases of the Skin. 

BY — 

dOHN \J. SHOEMAKER, A.M., M.D., 

Professor of Materia Medica, Pharmacology, Therapeutics, and Clinical Medicine, and Clinical Professor of 
of the Skin in the Medico-Chirurgical College of Philadelphia, etc. 



16mo. NEATLY BOUND IN CLOTH. PRICE, IN UNITED STATES AND CANADA, 
NET, »1.00, POST-PAID ; GREAT BRITAIN, 48. 3d. ; FRANCE, 6 fr. 30. 



The accompanying Table of Contents will give a general idea of the work : 
COiNTEItTTS. Part I. — History and Origin. Part II. — Process of Manufacture. Part 
'III. — Physiological Action of the Oleates. Part IV. — Therapeutic Effect of the Oleates. 
Part V. — Ointments: Local Medication of Skin Diseases. — Antiquity of Ointments.— DiflFerent Indi- 
cations for Ointments, Powders, Lotions, etc. — Information about Ointments: Scanty, Scattered, and 
Insufficient — Fats and Oils: Animal and Vegetable. — Their Chemical Composition. — Comparative 
Permeability of Oils into Skin ; of Animal, of Vegetable. Incorporation of Medicinal Substances into 
Fats: (i) Mode of Preparation, (2) Vegetable Powders and Extracts, (3) Alkaloids, (4) Mineral Sub- 
stances, (5) Petroleum Fats ; Chemical Composition; Uses and Disadvantages. — List of Officinal Oint- 
^ ments.— Indications. — Substances often Prescribed Extemporaneously in Ointment Form. — Indications. 
^ A FULL INDEX RENDERS THE BOOK CONVENIENT FOR QUICK REFERENCE. 

000 CRITICISMS OF FIRST EDITION. 



The profession in both countries is deeply in- 
debted to Dr. Shoemaker for his excellent work in 
this department of medicine. — IVilliatn IVhitla, 
M.D. (Q.U.J.). 

It is the most complete exposition of their action 
wliich has yet appeared. They are very valuable 
accessions to the materia medica, and should be 
familiar to every practitioner. — Medical and Sur- 
ffi, ill Reporter. 



To those of our readers who wish to learn the 
therapeutic effects of a class of preparations which 
are destined to grow in favor as their merits be- 
come more generally known, we commend this 
book. — Journal of Cutaneous and Venereal 
Diseases. 

No physician pretending to treat skin diseases 
should be without a copy of this very instructive 
little book. — Canada Medical Record. 



32 (F. A. DAVIS. Medical Publisher. Philadelphia, Pa.. U.S.A.) 



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